Established Evidence Results

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER, Expanded Insurance Coverage

Intervention Description: The present study uses a quasi-experimental design using data from the California Women's Health Survey and the Behavioral Risk Factor Surveillance System (BRFSS) for exposure and comparison groups, before and after California's Planning Access Care and Treatment waiver.

Intervention Results: Estimates from the California Women's Health Survey analysis indicate that among parents 100% to 200% of the FPL, the waiver led to an 8-percentage point increase in the receipt of a routine checkup and a 12-percentage point increase (p = .03) in discussion of birth control. There was an estimated 3-percentage point decline (p = .05) in current pregnancies among nulliparous women. Multistate analysis using the BRFSS confirmed positive effects on routine checkups (p < .01).

Conclusion: The waiver appears to have led to a reduction in pregnancy rates and increased receipt of reproductive health care, particularly routine checkups.

Study Design: QE: pretest-posttest non-equivalent control group

Setting: California

Population of Focus: Women in California with incomes under 200% of the Federal Poverty Level (FPL)

Data Source: California Women’s Health Survey and Behavioral Risk Factor Surveillance System

Sample Size: California Women’s Health Survey: Pre-waiver Intervention group ranges from n=220 to n=1,971 Control group ranges from n=206 to n=1,598 Post-waiver Intervention group ranges from n=399 to n=4,123 Control group ranges from n=497 to n=2,782 Behavioral Risk Factor Surveillance System: Pre-waiver Intervention (n=1,735); Control (n=2,564) Post-waiver Intervention (n=3,750); Control (n=10,963)

Age Range: 18-44

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER, Expanded Insurance Coverage

Intervention Description: Objectives: To use Medical Expenditure Panel Survey data to determine (1) whether adolescent well visit rates increased from the pre-ACA period to post-ACA period, and (2) whether caregivers' reports of past-year preventive services delivery increased from the pre- to post-ACA period among adolescents with any past-year health care visit.

Intervention Results: Under objective 1, we found that well-visit rates increased from 41% to 48% post-ACA implementation (odds ratio, 1.3; 95% CI, 1.2-1.5); minority and low-income groups had the greatest increases. Under objective 2, we found that among those with any past-year visit, most preventive services rates (8 of 9) increased post-ACA implementation (range, 2%-9%, absolute), with little or no change when controlling for demographic variables. Time alone with clinicians increased 1%, significant only when covariates were controlled (adjusted odds ratio, 1.2; 95% CI, 1.0-1.3).

Conclusion: Despite modest to moderate increases, with greatest gains for underserved youth, adolescent preventive care rates remain low, highlighting the need for increased efforts to bring adolescents into well care and improve clinician delivery of preventive care within their practices.

Study Design: QE: pretest-posttest

Setting: U.S.

Population of Focus: Adolescents ages 10-17

Data Source: Medical Expenditure Panel Survey

Sample Size: Total (N=25,695)

Age Range: Not specified

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), Collaboration with Local Agencies (State), Collaboration with Local Agencies (Health Care Provider/Practice), CLASSROOM_SCHOOL, PROFESSIONAL_CAREGIVER, Outreach (caregiver), Communication Tools, Distribution of Promotional Items (Classroom/School)

Intervention Description: In Michigan, a school-based outreach effort was piloted using existing school communication tools to identify children who are currently uninsured and may be eligible for state-subsidized health insurance. School districts were provided with two health insurance status collection forms to be included with the free and reduced school lunch application, and as part of the student registration packet and welcome materials for school. Completed forms were sent to a state registered application-assisting agency to ensure families can access the coverage and services they need. A final step in the process is outreach to eligible respondents by the Michigan Primary Care Association to help ensure that they receive information and access to the healthcare coverage and services they need.

Intervention Results: As a result of the survey, 156 children were identified as not having health insurance. This represents more than 44% of the 358 children who are eligible for State subsidized health insurance, in the participating school districts, but are uninsured. Integrating the collection of health insurance status into routine school communication channels is an effective way to identify children who do not have health insurance and may be eligible for state subsidized benefits.

Conclusion: 1. The Michigan Department of Community Health should lead the effort to work with the Michigan Department of Education to modify the Free and Reduced Lunch Application to capture whether or not the applicant has health insurance. 2. The Michigan Department of Community Health should lead the effort to incorporate into the direct certified free and reduced lunch eligibility process a systematic check as to whether or not the applicant has State subsidized health insurance. 3. The Michigan Department of Community Health should provide resources from the expected performance bonus to work with schools across the State to implement these changes.

Study Design: Cross-sectional pilot study

Setting: Schools (School districts in Van Buren County, Michigan)

Population of Focus: Uninsured children

Data Source: Survey data

Sample Size: 8,999 children

Age Range: School-aged children

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

Intervention Description: This observational, cohort study assessed the rate of insured visits for children pre- to post-ACA across four parental insurance groups (always insured, gained Medicaid, discontinuously insured, never insured) using Poisson mixed effects models.

Intervention Results: Insurance rates were highest (~95 insured visits/100 visits) for children of parents who were always insured; rates were lowest for children of parents who were never insured (~83 insured visits/100 visits). Children with a parent who gained Medicaid had 4.4% more insured visits post- compared to pre-ACA (adjusted relative rates = 1.044, 95% confidence interval: 1.014, 1.074). When comparing changes from pre- to post-ACA between parent insurance groups, children's insured visit rates were significantly higher for children of parents who gained Medicaid (reference) compared to children of parents who were always insured (adjusted ratio of rate ratio: 0.963, confidence interval: 0.935-0.992). Despite differences in Medicaid eligibility for children and adults, health insurance patterns were similar for linked families seen in CHCs.

Conclusion: Findings suggest consideration should be paid to parent health insurance options when trying to increase children's coverage.

Intervention Components (click on component to see a list of all articles that use that intervention): Health Insurance Coverage, Continuity of Care (Caseload), Expanded Insurance Coverage,

Intervention Description: N/A

Intervention Results: Of 30,678 children, 1875 (6.1%) were classified with Asthma, 294 (1.0%) with ASD, and 15,465 (50.4%) as Controls. Overall CoC was lower for Asthma (Mean = 0.58, SD 0.21) and ASD (M = 0.57, SD = 0.20) than Controls (M = 0.66, SD = 0.21); differences in well-care CoC were minimal. In regression models, lower overall CoC was found for Asthma (aOR = 0.90, 95% CI, 0.85-0.94). Lower overall and well-care CoC were associated with public insurance (aOR = 0.77, CI, 0.74-0.81; aOR = 0.64, CI, 0.59-0.69).

Conclusion: After accounting for patient and clinical-care factors, children with asthma, but not with ASD, in this primary-care network had significantly lower CoC compared to children without chronic conditions. Public insurance was the most prominent patient factor associated with low CoC, emphasizing the need to address disparities in CoC.

Study Design: Retrospective cohort study of electronic health records from office visits of children <9 years, seen ≥4 times between 2015 and 2019 in 10 practices of a community-based primary health care network in California. Three cohorts were constructed: 1) Asthma: ≥2 visits with asthma visit diagnoses; 2) ASD: same method; 3) Controls: no chronic conditions. CoC, using Usual Provider of Care measure (range > 0–1), was calculated for 1) all visits (overall) and 2) well-care visits. Fractional regression models examined CoC adjusting for patient age, medical insurance, practice affiliation, and number of visits.

Setting: California

Population of Focus: Children with chronic conditions

Sample Size: 30678

Age Range: <9

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

Intervention Description: We assessed whether state policies that allow children to remain covered in Medicaid for a 12-month period, regardless of fluctuations in income, are associated with health and health care outcomes, after controlling for individual factors and other Medicaid policies.

Intervention Results: Continuous eligibility was associated with improved rates of insurance, reductions in gaps in insurance and gaps due to application problems, and lower probability of being in fair or poor health. For children with special health care needs, it was associated with increases in use of medical care and preventive and specialty care access. However, continuous eligibility was not associated with health care utilization outcomes for the full sample.

Conclusion: Continuous eligibility may be an effective strategy to reduce gaps in coverage for children and reduce paperwork burden on Medicaid agencies.

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

Intervention Description: The Affordable Care Act (ACA) has the potential to address some of the health care needs of former foster youth through the Medicaid eligibility expansion to low-income adults and by extending Medicaid eligibility up to age twenty-six for former foster youth.

Intervention Results: Using the 2011-18 National Youth in Transition Database, we found that Medicaid expansion increased Medicaid coverage among former foster youth by 10.1 percentage points, and the age extension increased coverage by 3.4 percentage points. There is suggestive evidence of positive spillovers for both policies. Our findings imply that the ACA improved Medicaid coverage among former foster youth, with the largest effects from Medicaid expansion.

Conclusion: The modest effects of the Medicaid age extension may imply a need to revise enrollment, recertification, outreach, and eligibility determination processes to further increase Medicaid coverage among former foster youth.

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

Intervention Description: Research has shown that the ACA's Medicaid expansions have reduced uninsurance among women of reproductive age, but there may be variation in coverage effects even within this population. Using data from the American Community Survey (ACS) (n = 1,977,098) and a difference-in-differences approach, we compare Medicaid coverage among low-income adult women without children, postpartum mothers, and mothers of children older than one year in expansion states to non-expansion states, before and after the expansions. This nationally representative data is used to estimate the effect of ACA's Medicaid expansions on Medicaid coverage of low-income reproductive-aged women, and whether there are different relative effects for women without children, women who have given birth in the past year, and women who have a child older than one year.

Intervention Results: We fine variation in impacts within the population of reproductive-aged women. Childless women experience the largest gains in Medicaid coverage while postpartum mothers experience the smallest gains; mothers of children greater than one year old are in the middile. More specifically, the ACA’s Medicaid expansion increased Medicaid coverage among adult women with incomes between 101 and 200% of the federal poverty line (FPL) without children by 10.7 percentage points (54%, p < 0.01). Coverage of mothers with children older than one year increased by 9.5 percentage points (34%, p < 0.01). Coverage of mothers with infants rose by 7.9 percentage points (21%, p < 0.01). Within the population of adult reproductive-aged women, we find a "fanning out" of effects from the expansions. These results are consistent with ACA gains being the smallest among the groups least targeted by the ACA, but also show substantial gains (one fifth) even among postpartum mothers.

Conclusion: Within the population of adult reproductive-aged women, we find a “fanning out” of effects from the ACA’s Medicaid expansions. Childless women experience the largest gains in coverage while mothers of infants experience the smallest gains; mothers of children greater than one year old fall in the middle. These results are consistent with ACA gains being the smallest among the groups least targeted by the ACA, but also show substantial gains (one fifth) even among postpartum mothers.

Study Design: Quasi-experimental difference-in-difference

Setting: Policy (Medicaid expansion and non-expansion states)

Population of Focus: Reproductive aged low-income women at varying childbearing stages before and after the expansions

Sample Size: 1,977,098 low-income adult women

Age Range: N/A

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER, Expanded Insurance Coverage, HEALTH_CARE_PROVIDER_PRACTICE, Care Coordination, Public Insurance (Health Care Provider/Practice)

Intervention Description: The Coordinated Healthcare for Complex Kids (CHECK) model takes a broad approach to care coordination and health promotion by addressing social determinants of health, caregiver wellness, and mental health needs, in addition to chronic disease management, for children and youth with chronic health conditions. Community health workers deliver care coordination and assess individual and family needs, as well as patterns of health care utilization, to determine specific services offered to each family. The program is focused on lowering health care costs, especially regarding emergency department admissions, of pediatric patients with chronic health conditions.

Intervention Results: Overall Medicaid expenditures and utilization decreased considerably during the first year of the CHECK program for both participants and the usual care group. Notably, expenditures did not increase among CHECK participants, which has been noted in other care coordination programs. The rate of inpatient and ED utilization decreased for both groups. The mean (SD) inpatient utilization before enrollment in CHECK was 63.0 (344.4) per 1000 PYs for the intervention group and 69.3 (370.9) per 1000 PYs for the usual care group, which decreased to 43.5 (297.2) per 1000 PYs and 47.8 (304.9) per 1000 PYs, respectively, after the intervention.

Conclusion: Overall Medicaid expenditures and health care utilization (hospital and ED) decreased similarly for both CHECK participants and the usual care group.

Study Design: RCT

Setting: Community (Coordinated Healthcare for Complex Kids (CHECK) program; Illinois Medicaid)

Population of Focus: Children and young adults with chronic disease who receive public insurance

Data Source: Illinois Medicaid paid claims for CHECK participants using the Care Coordination Claims Data (CCCD) provided by the Illinois Department of Healthcare and Family Services

Sample Size: 6,245 children and young adults (3,119 in the control group and 3,126 in the intervention group)

Age Range: Children <1 and youth >18 (mean age was 11.3 years)

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): PAYER, Expanded Insurance Coverage, HEALTH_CARE_PROVIDER_PRACTICE, Public Insurance (Health Care Provider/Practice), Educational Material (Provider), Collaboration with Local Agencies (State), Collaboration with Local Agencies (Health Care Provider/Practice), Nurse/Nurse Practitioner, PROFESSIONAL_CAREGIVER, Patient Navigation (Assistance), Care Coordination, STATE, Multicomponent Approach

Intervention Description: The Healthy Beginnings system of care in Atlanta, GA connects children and their families to health insurance and a medical home model of care to support children’s health and development. The main components are care management + education and parent engagement + collaborative partnerships. A registered nurse, known as the health navigator, supports parents and helps them learn how to work with health care professionals on behalf of their children; they also connect parents to the Center for Working Families to ensure that they receive public benefits for which they are eligible.

Intervention Results: Healthy Beginnings coordinated care approach has ensured that participating children and families have health insurance (97%) and receive regular immunizations (92%), ongoing health care from a primary care physician and dental health provider, and regular developmental screenings (98%) and follow-up care. Healthy Beginnings has dramatically increased children’s access to health care and forms the basis for a cost-effective approach that can be replicated in other communities.

Conclusion: 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 a cost-effective approach that can be replicated in other communities.

Study Design: Program evaluation

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

Population of Focus: Low-income young children and families

Data Source: Questionnaire data

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), STATE, Perinatal Committees/Councils

Intervention Description: Numerous states have implemented policies expanding public insurance eligibility or subsidizing private insurance for parents. Under the ACA, states retain significant flexibility in terms of eligibility and program structure. Approaches to state-level expansions to parents include providing public health insurance with or without an enrollee premium and providing subsidies for private health insurance. The Oregon Experiment (Medicaid expansion) gave a subset of uninsured, low-income adults access to Medicaid through a randomized selection process.

Intervention Results: Children’s odds of having Medicaid or CHIP coverage increased when their parents were randomly selected to apply for Medicaid; findings demonstrate a causal link between parents’ access to Medicaid coverage and their children’s coverage. Children whose parents were randomly selected to apply for Medicaid had 18% higher odds of being covered in the first 6 months after parent’s selection compared with children whose parents were not selected. In the immediate period after selection, children whose parents were selected to apply for Medicaid significantly increased from 3830 (61.4%) to 4152 (66.6%) compared with a non-significant change from 5049 (61.8%) to 5044 (61.7%) for children whose parents were not selected to apply. The effect remained significant during months 7 to 12; months 13 to 18 showed a positive but not significant effect. Children whose parents were selected and obtained coverage had more than double the odds of having coverage compared with children whose parents were not selected and did not gain coverage.

Conclusion: Children’s odds of having Medicaid or CHIP coverage increased when their parents were randomly selected to apply for Medicaid. Children whose parents were selected and subsequently obtained coverage benefited most. This study demonstrates a causal link between parents’ access to Medicaid coverage and their children’s coverage.

Study Design: Randomized natural experiment; generalized estimating equation models

Setting: Policy (Oregon Medicaid expansion program)

Population of Focus: Children whose parents participated in the Oregon Experiment (Medicaid expansion program)

Data Source: The Oregon Experiment’s reservation list data; Oregon Health Plan (OHP) administrative data

Sample Size: 14,409 children

Age Range: 2-18 Years

Intervention Components (click on component to see a list of all articles that use that intervention): Expanded Insurance Coverage, Guideline Change and Implementation, Quality Improvement,

Intervention Description: Oregon’s Medicaid expansion provided an opportunity to investigate a potential causal relationship between insurance coverage for parents and their children. This expansion, often referred to as the Oregon Experiment, gave a subset of uninsured, low-income adults access to Medicaid through a randomized selection process. In 2008, Oregon’s Medicaid program, the Oregon Health Plan (OHP), sought to enroll 10,000 non–categorically eligible (i.e., not meeting federally mandated Medicaid eligibility criteria) low-income adults into its expansion program (OHP Standard), which had been closed to new enrollment since 2004. During a random selection process, uninsured, low-income adults were encouraged to put their names on a reservation list. From this list, there were 8 random drawings; individuals selected in these drawings were invited to apply for OHP coverage. The reservation list included more than 90,000 registrants; of these, approximately 30,000 were randomly selected to apply and about 10,000 were ultimately enrolled in OHP. Not everyone selected to apply completed an application, and not all applicants met enrollment eligibility criteria. This study of the Oregon Experiment examined the longitudinal effect of parents randomly selected to apply for Medicaid on their child’s Medicaid or CHIP coverage. The objective was to estimate the effect on a child’s health insurance coverage status when (1) a parent randomly gains access to health insurance and (2) a parent obtains coverage.

Intervention Results: Children whose parents were randomly selected to apply for Medicaid had 18% higher odds of being covered in the first 6 months after parent’s selection compared with children whose parents were not selected. In the immediate period after selection, children whose parents were selected to apply for Medicaid significantly increased from 3830 (61.4%) to 4152 (66.6%) compared with a non-significant change from 5049 (61.8%) to 5044 (61.7%) for children whose parents were not selected to apply. Children whose parents were randomly selected to apply for Medicaid had 18% higher odds of being covered in the first 6 months after parent’s selection compared with children whose parents were not selected (adjusted odds ratio [AOR] = 1.18; 95% CI, 1.10–1.27). The effect remained significant during months 7 to 12 (AOR = 1.11; 95% CI, 1.03–1.19); months 13 to 18 showed a positive but not significant effect (AOR = 1.07; 95% CI, 0.99–1.14). Children whose parents were selected and obtained coverage had more than double the odds of having coverage compared with children whose parents were not selected and did not gain coverage.

Conclusion: Children whose parents were randomly selected to apply for coverage through the Oregon Experiment had higher rates of OHP coverage than children whose parents were not selected. Among children whose parents were selected, those whose parents obtained coverage benefited the most. This study demonstrates a causal link between Medicaid coverage for parents and their children. To maximize children’s health insurance coverage rates, parents must also have opportunities to obtain coverage

Study Design: Randomized natural experiment; generalized estimating equation models

Setting: Policy (Oregon Medicaid expansion program)

Population of Focus: Parents and Children

Sample Size: 14,409 children

Age Range: 2-18 years

Intervention Components (click on component to see a list of all articles that use that intervention): Expanded Insurance Coverage, PAYER

Intervention Description: This study looked at the impact of the State Children's Health Insurance Program (SCHIP) on access to care and satisfaction among vulnerable subgroups of children in three diverse states - Florida, Kansas, and New York. The vulnerable subgroups included minority children, children with special health care needs, and children who were uninsured for long periods before enrolling. The study used a pre-post design, surveying newly enrolled children and their families about the 12 months before enrollment and again about the 12 months after enrollment.

Intervention Results: This study provides consistent evidence, from three very diverse states with heterogeneous populations and distinct programs (Florida, Kansas, and New York), that the State Children's Health Insurance Program (SCHIP) increased access to and satisfaction with health care among enrolled low-income children and that vulnerable children-minorities, children and adolescents with special health care needs, and children who were uninsured for long periods of time-shared in these improvements.

Conclusion: The study provides evidence from three very different states that SCHIP conferred benefits in access and satisfaction to the most vulnerable low-income children, not just average enrollees. As states face budget pressures and consider SCHIP policy changes, policymakers should consider these findings that the program improved care for the subgroups that are most at risk for poor access and unmet health care needs. Some areas for further improvement include increasing preventive care for Hispanic children and reducing the still high level of unmet need among CSHCN.

Study Design: QE: pretest-posttest

Setting: Florida, New York, Kansas

Population of Focus: Children and adolescents ages 1-18 who had enrolled in CHIP between July 2000 and March 2001

Data Source: Interviews

Sample Size: Florida (n=918)4 N=adolescent ages 12-18 New York (n=2,290) N=all children ages 1-18 Kansas (n=434) N=all children ages 1-18

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Medicaid Reform, Expanded Insurance Coverage,

Intervention Description: Maternal coverage and care use were compared among women with family incomes 100% to 138% of the federal poverty level (FPL) residing in 10 Medicaid expansion sites (exposure group) who gained Medicaid eligibility under the Affordable Care Act and in 5 nonexpansion sites (comparison group) who gained marketplace eligibility before (2011-2013) and after (2015-2018) insurance expansion implementation.

Intervention Results: Medicaid eligibility relative to marketplace eligibility was associated with significantly increased Medicaid coverage (20.3 percentage points), decreased private insurance coverage (−10.8 percentage points), and decreased uninsurance (−8.7 percentage points) in the preconception period. It was also associated with increased postpartum Medicaid (17.4 percentage points) and increased adequate prenatal care (4.4 percentage points) but not with significant changes in early prenatal care, postpartum checkups, or postpartum contraception.

Conclusion: In this cohort study, eligibility for Medicaid was associated with increased Medicaid, lower preconception uninsurance, and increased adequate prenatal care use. The lower rates of preconception uninsurance among Medicaid-eligible women suggest that women with low incomes were facing barriers to marketplace enrollment, underscoring the potential importance of reducing financial barriers for the population with low incomes.

Study Design: Cohort study

Setting: 10 Medicaid expansions states; 5 non-expansion states

Population of Focus: Women with low incomes

Sample Size: 11432

Age Range: >18

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), Educational Material (Provider), PARENT_FAMILY, Training (Parent/Family), PROFESSIONAL_CAREGIVER, Outreach (caregiver), PATIENT_CONSUMER, Peer Counselor, Parent Mentors

Intervention Description: The aim of the Kids’ Health Insurance by Educating Lots of Parents (Kids’ HELP) study was to evaluate the effects of parent mentors – Latino parents with children covered by Medicaid or the Children’s Health Insurance Program (CHIP) – on insuring Latino children in a community-based trial of uninsured children from 2011-2015. Parent mentors were trained to assist families in getting insurance coverage, accessing health care, and addressing social determinants of health. The intervention group was assigned parent mentors – trained, fluently bilingual Latino parents who had at least one child insured by Medicaid or CHIP for at least one year. Parent mentors attended a two-day training and received training manuals in English and Spanish with 9 training topics and one on sharing experiences. Parents mentors provided 8 services to intervention children and families (e.g., teaching about types of insurance programs and application processes; helping parents complete and submit children’s insurance applications; acting as family advocates by liaising between families and Medicaid or CHIP agencies; and helping parents complete and submit applications for coverage renewal).

Intervention Results: The study found that parent mentors were more effective than traditional methods in insuring children (95% vs. 69%), achieving faster coverage and greater parental satisfaction, reducing unmet health care needs, providing children with primary care providers, and improving the quality of well-child and subspecialty care. Children in the parent-mentor group had higher quality of overall and specialty care, lower out-of-pocket spending, and higher rates of coverage two years after the end of the intervention (100% vs. 70%). Parent mentors are highly effective in insuring uninsured Latino children and eliminating disparities. Parent mentors, as a special category of community health workers, could be an excellent fit with and complement to current state community health worker models. This RCT documented that the Kids’ HELP intervention is significantly more efficacious than traditional Medicaid and CHIP methods of insuring Latino children. Kids’ HELP eliminates coverage disparities for Latino children, insures children more quickly and with greater parental satisfaction than among control parents, enhances health care access, reduces unmet needs, improves the quality of well-child and subspecialty care, reduces out-of-pocket spending and family financial burden, empowers parents, ad creates jobs.

Conclusion: Parent mentors are highly effective in insuring uninsured Latino children and eliminating disparities.

Study Design: RCT

Setting: Community (Communities in Dallas County, Texas with the highest proportions of uninsured and low-income minority children)

Population of Focus: Uninsured children 0-18 years old whose primary caregiver identified them as Latino and uninsured and reported meeting Medicaid/CHIP eligibility criteria for the child

Data Source: Kids’ HELP trial data; questionnaires

Sample Size: 155 subjects (children and parents); 75 in the control group and 80 in the intervention group

Age Range: 0-18 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), Educational Material (Provider), PARENT_FAMILY, Training (Parent/Family), PROFESSIONAL_CAREGIVER, Outreach (caregiver), PATIENT_CONSUMER, Peer Counselor, Parent Mentors

Intervention Description: This study examined the effects of parent mentors on insuring minority children in the Kids’ Health Insurance by Educating Lots of Parents (Kids’ HELP) program. Parent mentors were experienced parents with ≥1 Medicaid/CHIP-covered child who received 2 days of training, then assisted families for 1 year with insurance applications, retaining coverage, medical homes, and social needs; controls received traditional Medicaid/CHIP outreach. Parent mentors received monthly stipends for each family mentored. Parents mentors and intervention participants were matched by race/ethnicity and zip code, whenever possible. Latino families were matched with fluently bilingual Latino parent mentors. Session content for the 2-day training was based on training provided to community case managers in the research team’s previous successful RCT and addressed 9 topics (e.g., why health insurance is so important; being a successful parent mentor; parent mentor responsibilities; Medicaid and CHIP programs and the application process; the importance of medical homes).

Intervention Results: In the Kids’ HELP trial, the intervention was more effective than traditional outreach/enrollment in insuring uninsured minority children, resulting in 95% of children obtaining insurance vs. 68% of controls. The intervention also insured children faster, and was more effective in renewing coverage, improving access to medical and dental care, reducing out-of-pocket costs, achieving parental satisfaction and quality of care, and sustaining insurance after intervention cessation. This is the first RCT to evaluate the effectiveness of parent mentors in insuring uninsured children. Kids’ HELP could possibly save $12.1 to $14.1 billion. Parent mentors were more effective in improving access to primary, dental, and specialty care; reducing unmet needs, achieving parental satisfaction with care, and sustaining long-term coverage. Parent mentors resulted in lower out-of-pocket costs for doctor and sick visits, higher well-child care quality ratings, and higher levels of parental satisfaction and respect from children’s physicians.

Conclusion: PMs are more effective than traditional Medicaid/CHIP methods in insuring uninsured minority children, improving health care access, and achieving parental satisfaction, but are inexpensive and highly cost-effective.

Study Design: RCT

Setting: Community (Communities in Dallas County, Texas with the highest proportions of uninsured and low-income minority children)

Population of Focus: Primary caregiver had ≥1 child 0 to 18 years old who lacked health insurance but was Medicaid/CHIP eligible, and the primary caregiver self-identified the child as Latino/Hispanic or African-American

Data Source: Kids’ HELP trial data; questionnaires; national, state, and regional surveys

Sample Size: 237 participants; 114 in the control group and 123 in the intervention group

Age Range: 0-18 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, Education/Training (caregiver), Collaboration with Local Agencies (State), Educational Material (caregiver), STATE, Multicomponent Approach

Intervention Description: In New York, to maximize comprehensive insurance coverage for CYSHCN, a Service Integration Model was formed between the Office of Health Insurance Services and the Early Intervention Program. The 3 key components include educational messaging (jointly prepared messages about health insurance benefits and enrollment assistance offered by the Office of Health Insurance Services through the Early Intervention Program) + data from program databases (data matching with the Early Intervention Program) + individual counseling using program staff (incorporation of the Office of Health Insurance Services program staff—child benefit advisors—to work directly with parents of children in the Early Intervention Program to facilitate enrollment and renewal. The model overcomes enrollment barriers by using consumer friendly enrollment materials and one-on-one assistance, and shows the benefits of a comprehensive and collaborative approach to assisting families with enrollment into public health insurance.

Intervention Results: Since 2008, more than 5,000 children in the Early Intervention Program have been successfully enrolled and coverage renewed in Medicaid through the Service Integration Model. In 2008, the study team found that children in the Early Intervention Program had a 34% churning rate for Medicaid because of enrollment barriers and misconception of the Early Intervention Program as a replacement for Medicaid. By 2010, the churning rate for clients assisted through Office of Health Insurance Services was reduced from 34% to 8%. The Office of Health Insurance Services will modify the Service Integration Model to respond to New York State’s implementation of the Health Insurance Exchange required by the 2010 ACA. Partnerships across government programs and agencies offer opportunities to enroll hard-to-reach populations into public health insurance. The model reflects how government programs can work together to improve rates of enrollment and retention in public health insurance. The key elements of integration of program messages, data matching, and staff involvement allow for the model to be tailored to the specific needs of other government programs.

Conclusion: The model overcomes enrollment barriers by using consumer-friendly enrollment materials and one-on-one assistance, and shows the benefits of a comprehensive and collaborative approach to assisting families with enrollment into public health insurance.

Study Design: Program evaluation

Setting: Community (New York City Department of Health and Mental Hygiene's Office of Health Insurance Services and the Early Intervention Program)

Population of Focus: Uninsured and underinsured young children with special health care needs in New York City participating in the Early Intervention Program

Data Source: Evaluation data

Sample Size: 6,500 children in early intervention with a Medicaid number

Age Range: 0-3 years

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

Intervention Description: Young adults historically have had the highest uninsured rates among all age groups. In 2014, in addition to Medicaid expansion for adults with low income (≤133% FPL) through the ACA, Massachusetts also extended eligibiligy for children (≤150% FPL) to beneficiaries aged 19 to 20 years. This study examined whether Medicaid expansion in Massachusetts changed coverage continuity for child Medicaid enrollees entering young adulthood. Data from the Massachusetts All-Payer Claims Database (2012 to 2016) was used to compare coverage for Medicaid beneficiaries turning age 19 years before and after Medicaid expansion. Monthly coverage was examined for each cohort for 3 years as beneficiaries aged from 18 and 19 years to 19 and 20 years to 20 and 21 years. Analyses were performed between November 1, 2020, and May 12, 2022. In each year, the likelihood of being uninsured or having Medicaid, employer-sponsored insurance, or individual commercial coverage for 3 or more months was examined along with the likelihood of having continuous Medicaid enrollment for 12 or more and 24 or more months.

Intervention Results: In this cohort study of 41,247 young adults, Medicaid enrollees who turned 19 after or before Medicaid expansion were significantly less likely to have 3 or more months without insurance coverage at ages 18 to 19 and 19 to 20 years and more likely to have continuous Medicaid coverage for24 or more months. Differences in the likelihood of having 3 or more uninsured months diminished at ages 20 to 21 years, when both groups had access to Medicaid (i.e., in calendar years 2014 for the preexpansion cohort and 2016 for the postexpansion cohort). The combination of Federal and state Medicaid expansions -- expanding Medicaid to lower-income adults and increasing the age threshold for child Medicaid eligibility -- was associated with reductions in insurance disruptions and coverage gaps among child Medicaid enrollees entering young adulthood.

Conclusion: In this cohort study of young adults in Massachusetts, the combination of expanding Medicaid to lower-income adults and increasing the age threshold for child Medicaid eligibility was associated with reduced likelihood of becoming uninsured among Medicaid enrollees entering adulthood.

Study Design: Cohort study

Setting: Policy (Medicaid expansion in Massachusetts)

Population of Focus: Young adults, 18-20 yr olds

Sample Size: 41,247 young adults

Age Range: 18-20 year olds

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER, Expanded Insurance Coverage

Intervention Description: Using multi-year responses from the Behavioral Risk Factor Surveillance System, we examined the association between the ACA and participation in and adherence to Pap testing and HPV vaccination behaviors as set by the ACS. The sample included women aged 21–29 who completed the survey between 2008 and 2018 (every other year) and who live in 24 US States (N = 37,893).

Intervention Results: Results showed significant decreases in Pap testing rates but increases in the uptake of the HPV vaccine series for all age groups and across all demographics. Post-ACA year significantly predicted increases in HPV + Pap co-testing participation and adherence. Women with health insurance coverage were more likely to engage in both behaviors.

Conclusion: Findings raise concerns around declines in the proportion of women receiving and adhering to Pap testing guidelines. A need exists for research to examine the role of increases in HPV vaccination uptake on decreases in Pap testing. Moreover, effective strategies should target increases in cervical cancer screening uptake among women vaccinated against HPV.

Setting: U.S. healthcare system

Population of Focus: Women ages 21-29 who lived in U.S. and completed BRFSS survey

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER, Expanded Insurance Coverage

Intervention Description: First, we compared service receipt among continuing Medicaid enrollees pre- and post-ACA. We then compared receipt among new post-ACA Medicaid enrollees to receipt by continuing enrollees after ACA implementation. Using Medicaid enrollment and claims data, we identified well-woman visits, contraceptive counseling, contraceptive services, sexually transmitted infection (STI) screening, and cervical cancer screening among women ages 15–44 in years when not pregnant. For pre-ACA enrollees, we assessed pre-ACA receipt in 2011–2013 (n = 83,719) and post-ACA receipt in 2014–2016 (n = 103,225). For post-ACA enrollees we similarly assessed post-ACA service receipt (n = 73,945) and compared this to service receipt by pre-ACA enrollees during 2014–2016.

Intervention Results: We estimated logistic regression models to compare service receipt over time and between enrollment groups. Among pre-ACA enrollees we found lower receipt of all services post-ACA. Adjusted declines ranged from 7.0 percentage points (95% CI: −7.5, −6.4) for cervical cancer screening to 0.4 percentage points [−0.6, −0.2] for STI screening. In 2014–2016, post-ACA enrollees differed significantly from pre-ACA enrollees in receipt of all services, but all differences were <2 percentage points.

Conclusion: Despite small declines in receipt of several preventive reproductive services among prior enrollees, the ACA resulted in Medicaid financing of these services for a large number of newly enrolled low-income women in Oregon, which may eventually lead to population-level improvements in reproductive health. These findings among women in Oregon could inform Medicaid coverage efforts in other states.

Setting: Oregon state Medicaid expansion program

Population of Focus: Low-income non-pregnant women aged 15–44 enrolled in Oregon's Medicaid program in 2011–2016

Intervention Components (click on component to see a list of all articles that use that intervention): Medicaid Reform, Expanded Insurance Coverage,

Intervention Description: The expansion of Medicaid under the Affordable Care Act (ACA) in Colorado in 2013-2015, compared with the state of Utah, which did not expand Medicaid.

Intervention Results: Before Medicaid expansion, the mean number of postpartum outpatient visits in Medicaid was higher in Colorado than in Utah. After expansion, the number of visits increased in Colorado and decreased in Utah, resulting in a 17.3 percent increase in outpatient utilization relative to the baseline rate in Colorado, or 0.52 additional Medicaid-financed visits in the six months after delivery, compared to women in Utah. Utilization increases were significantly greater among women who experienced severe maternal morbidity at the time of their deliveries. Among these women, Colorado’s expansion was associated with 1.3 Medicaid-financed postpartum outpatient visits compared to 0.5 visits among women without severe maternal morbidity, a relative increase of 46.3 percent from Colorado’s baseline mean

Conclusion: After Medicaid expansion in Colorado but not Utah, new mothers in Utah experienced higher rates of Medicaid coverage loss and accessed fewer Medicaid-financed outpatient visits during the six months postpartum, relative to their counterparts in Colorado. The effects of Medicaid expansion on postpartum Medicaid enrollment and outpatient utilization were largest among women who experienced significant maternal morbidity at delivery. These findings provide evidence that expansion may promote the stability of postpartum coverage and increase the use of postpartum outpatient care in the Medicaid program.

Study Design: Two-state claims-based analysis of the effect of Medicaid expansion on postpartum Medicaid coverage and use of postpartum outpatient care

Setting: Birth settings where Medicaid is accepted

Population of Focus: Women who had live births paid for by Medicaid during the period January 2013-June 2015 in Colorado and Utah.

Sample Size: 25,805 deliveries from 24,528 women in Utah and 44,647 deliveries from 42,144 women in Colorado.

Age Range: ≥19

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), NATIONAL, Policy/Guideline (National)

Intervention Description: Numerous states have implemented policies expanding public insurance eligibility or subsidizing private insurance for parents. Under the ACA, states retain significant flexibility in terms of eligibility and program structure. This study assessed the impact of parental health insurance expansions from 1999 to 2012 on the likelihood that parents are insured; their children are insured; both the parent and child within a family unit are insured; and the type of insurance. Cross-state and within-state multivariable regression models estimated the effects of health insurance expansions targeting parents using 2-way fixed effect modeling and difference-in-difference modeling.

Intervention Results: Cross-state analyses demonstrate that public expansions without premiums and special subsidized plan expansions had the largest effects on parental coverage and increased the likelihood of jointly insuring the parent and child. Expansions increased parental coverage by 2.5 percentage points and increased the likelihood of both parent and child being insured by 2.1 percentage points. Substantial variation was observed by type of expansion. Public expansions without premiums and special subsidized plan expansions had the largest effects on parental coverage and increased the likelihood of jointly insuring both the parent and child. Higher premiums were a substantial deterrent to parents’ insurance. Our findings suggest that premiums and the type of insurance expansion can have a substantial impact on the insurance status of the family. The most effective expansions for parental insurance coverage were those for traditional Medicaid coverage without premiums and for special subsidized plans that subsidized costs for individuals to purchase state-sponsored plans. These findings can help inform states as they continue to make decisions about expanding Medicaid under the Affordable Care Act to cover all family members.

Conclusion: Our findings suggest that premiums and the type of insurance expansion can have a substantial impact on the insurance status of the family. These findings can help inform states as they continue to make decisions about expanding Medicaid under the Affordable Care Act to cover all family members.

Study Design: Cross-sectional analysis of data

Setting: Policy (States)

Population of Focus: Parents ≤ 300% FPL who were eligible for insurance expansions in selected states

Data Source: 2000–2013 March supplements to the Current Population Survey, with data from the Medical Expenditure Panel Survey—Insurance Component and the Area Resource File

Sample Size: 19 expansion states (representing 28 expansions) and 22 control states without a parental expansion during the study period

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): 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): Medicaid, Expanded Insurance Coverage

Intervention Description: The evaluation included a large survey conducted in 2012 of CHIP enrollees and disenrollees in the 10 states, and Medicaid enrollees and disenrollees in three of these states. It also included case studies conducted in each of the 10 survey states in 2012 and a national telephone survey of CHIP administrators conducted in early 2013. Data from the Current Population Survey and the American Community Survey were analyzed to document national coverage trends from 1997 to 2012.

Intervention Results: Together with Medicaid, CHIP has helped fuel a decline in the number of uninsured children from 11.4 million (15 percent of children) in 1997 to 6.6 million (9 percent of children) in 2012. As of March 2014, 8.13 million children were enrolled in CHIP at some point in FFY 2013.

Conclusion: The evaluation found CHIP to be successful in nearly every area examined. CHIP succeeded in expanding health insurance coverage to the population it is intended to serve, particularly children who would otherwise be uninsured, increasing their access to needed health care, and reducing the financial burdens and stress on families associated with meeting children’s health care needs. These positive impacts were found for children and families in states with different CHIP program structures and features, across demographic and socioeconomic groups, and for children with different health needs. Medicaid and CHIP have worked as intended to provide an insurance safety net for low-income children during economic hard times. Awareness of both Medicaid and CHIP was high among low-income families, most newly enrolling families found the application process at least somewhat easy, and the vast majority of children remained enrolled through the annual renewal period. The evaluation also identified a few areas where there is room for improvement. One in four children in CHIP had some type of unmet need, and although most CHIP enrollees received annual well-child checkups, fewer than half received key preventive services such as immunizations and health screenings during those visits, and fewer than 40 percent had afterhours access to a usual source of care provider. While most CHIP enrollees received annual dental checkups, a significant share of them did not get recommended follow-up dental treatment. There is also room for improvement in reducing the percentage of children who cycle off and back on to Medicaid and CHIP, and reducing gaps in coverage associated with moving between Medicaid and separate CHIP programs. And while participation rates have grown to high levels in most states, further effort could be targeted to the 3.7 million children who are eligible for Medicaid or CHIP but remain uninsured

Study Design: Survey

Setting: National Level and Alabama, California, Florida, Louisiana, Michigan, New York, Ohio, Texas, Utah, and Virginia

Data Source: N/A

Sample Size: N/A

Age Range: N/A

Intervention Components (click on component to see a list of all articles that use that intervention): Expanded Insurance Coverage, PAYER

Intervention Description: The evaluation of the Children's Health Insurance Program (CHIP) mandated by the CHIP Reauthorization Act of 2009 was conducted by Mathematica Policy Research and the Urban Institute. The evaluation included case studies in 10 states selected to provide geographic and demographic diversity, a nationwide telephone survey of state CHIP administrators, analysis of state eligibility and enrollment data, and a survey of 12,000 CHIP enrollees and disenrollees in the 10 study states, as well as 3,400 Medicaid enrollees and disenrollees in 3 of the states. The surveys collected information on health status, service utilization, and families' experiences with application, enrollment, and renewal processes. Other components included analysis of data from national surveys to examine coverage trends and Medicaid/CHIP participation rates.

Intervention Results: The evaluation found that CHIP, together with Medicaid, has significantly reduced uninsurance among low-income children, from 25% in 1997 to 13% in 2012, with coverage disparities narrowing for Hispanic children. Medicaid/CHIP participation rates increased from 82% in 2008 to 88% in 2012, with 21 states achieving rates above 90%. Relatively few CHIP enrollees had private coverage prior to enrollment, and direct substitution of CHIP for private coverage was estimated to be as low as 4%. The vast majority of children remained enrolled in CHIP for at least 28 months, and most disenrollees exited due to ineligibility. Compared to uninsured children, CHIP enrollees experienced better access to care, fewer unmet needs, and greater financial protection. While comparable to private coverage on many measures, CHIP enrollees had better access to dental care and much lower financial burden. Despite high rates of preventive visits, nearly 25% of enrollees had unmet needs and many were not receiving key

Conclusion: The evaluation demonstrated CHIP's success in expanding health insurance coverage for low-income children, improving their access to health care, and reducing financial burden and stress for their families across states with diverse program designs. Despite progress, further efforts are needed to cover the remaining 3.7 million uninsured children who are eligible for Medicaid or CHIP and improve retention and continuity of coverage. With the uncertain future of CHIP funding beyond 2015 and the changing health care landscape under the Affordable Care Act, the evaluation's insights on the value of CHIP and children's unique health care needs are particularly relevant for policymakers. Continuing to build on CHIP's accomplishments in providing affordable, comprehensive coverage will be critical to ensure that all low-income children can obtain the health care they need.

Study Design: QE: non-equivalent control group

Setting: Ten states: Alabama, California, Florida, Louisiana, Michigan, New York, Ohio, Texas, Utah, and Virginia

Population of Focus: Youth ages 13 and older enrolled in CHIP for at least 12 consecutive months

Data Source: 2012 Congressionally Mandated Survey of CHIP and Medicaid Enrollees and Disenrollees

Sample Size: Established enrollees (n≈2345) Uninsured children (n≈381) N=children >13 years

Age Range: Not specified

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), Medicaid

Intervention Description: The Massachusetts Medicaid Buy-In program, called MassHealth CommonHealth, allows families of children with disabilities to buy into the state’s Medicaid program to cover more services and to defray costs that private insurance does not cover. Children with disabilities who do not have other insurance can use the program as their sole insurance; Children with disabilities who have other insurance can use the program as a secondary payer to supplement coverage and reduce families’ out-of-pocket costs due to the deductible, co-payments, and coinsurance for the child. Adopting a Medicaid Buy-In program may be an effective way for states to create a pathway to Medicaid for children with disabilities whose family income is too high for Medicaid and who have unmet needs and/or whose families incur high out-of-pocket costs for their care.

Intervention Results: This study suggests that the MassHealth CommonHealth Buy-In program improves access to care for children with disabilities by providing the benefits that were limited in scope or unavailable through other insurance before enrollment and by making available services more affordable. Parents reported that this increased access resulted in improvements in their child’s health or functioning, reduced stress on the parents and families, and reduced financial strain. Overall, many respondents appreciated the CommonHealth program. Despite these benefits, other families reported that they continued to face barriers in access to care for their children with disabilities. They reported difficulty in finding mental health or dental care, as many of these providers (as well as other specialists) did not accept MassHealth. Even with CommonHealth, families still had high out-of-pocket costs due to services that are not covered or high CommonHealth premiums. Families also struggled with complex paperwork requirements. Policy and administrative changes could improve the program and further increase access to care for children with complex, costly conditions. Adopting a Medicaid Buy-In program may be an effective way for other states to create a pathway to Medicaid for children with disabilities whose family income is too high for Medicaid and who have unmet needs and/or whose families incur high out-of-pocket costs for their care.

Conclusion: Data suggest that CommonHealth improves access to care for children with disabilities by providing the benefits that were limited in scope or unavailable through other insurance before enrollment and by making available services more affordable. Policy and administrative changes could improve the program and further increase access to care for children with complex, costly conditions. Adopting a Medicaid Buy-In program may be an effective way for states to create a pathway to Medicaid for children with disabilities whose family income is too high for Medicaid and who have unmet needs and/or whose families incur high out-of-pocket costs for their care.

Study Design: Survey

Setting: Policy (CommonHealth, Massachusetts's Medicaid Buy-In program)

Population of Focus: Parents and caregivers of Massachusetts children with disabilities enrolled in CommonHealth

Data Source: Survey data

Sample Size: 615 families

Age Range: 0-18 years

Intervention Components (click on component to see a list of all articles that use that intervention): Policy/Guideline (State), Expanded Insurance Coverage, Other (Provider Practice),

Intervention Description: The intervention described in the study involved the implementation of two policy changes in Nova Scotia, Canada: 1) the implementation of a publicly-funded universal influenza vaccination program in the 2010–2011 influenza season, and 2) the addition of pharmacists as immunizers in 2013. The aim of these changes was to improve vaccine uptake by eliminating cost as a barrier and increasing convenience and possibly access ,[object Object],. The study aimed to investigate any changes in influenza vaccine coverage following the implementation of each policy change ,[object Object],. The study compared influenza vaccine coverage between the pre-universal program period, the universal publicly funded program period, and the universal publicly funded program with the addition of pharmacists period ,[object Object],.

Intervention Results: The results of the study showed an increase in influenza vaccine coverage immediately following the implementation of the two studied policy changes. Vaccine coverage increased from 36.4% to 38% following the implementation of the universally funded vaccine policy. Following the implementation of pharmacists as immunizers, coverage increased from 35.7% to 41.7% ,[object Object],. Despite the initial increase in coverage observed, a reduction in coverage was observed in the two years following the addition of pharmacists as immunizers ,[object Object],. The study also found that coverage in individuals aged 65 years and older remained relatively consistent with the addition of a universally funded vaccination program compared to the pre-universal study years ,[object Object],.

Conclusion: The addition of a universally funded vaccination policy and the addition of pharmacists as providers of the influenza vaccine resulted in increases in vaccine coverage initially. Additional research is needed to determine the long-term impacts of the policy changes on vaccination coverage and to identify other important factors affecting vaccine uptake.

Study Design: the main study discussed in the file aimed to compare influenza vaccine coverage between three different policy periods: 1) pre-universal influenza vaccination program; 2) universal publicly funded program; and 3) universal publicly funded program with the addition of pharmacists 6. The study used census data and aggregate immunization data obtained from the Nova Scotia Department of Health and Wellness 6. The study design was observational, as it analyzed existing data rather than conducting a randomized controlled trial or other experimental study.

Setting: Nova Scotia, Canada

Population of Focus: The target audience of the PDF file is likely researchers, healthcare professionals, and individuals interested in public health and related topics. The scientific literature and resources included in the file are intended for those with a background in the field and may contain technical language and data analysis.

Sample Size: The PDF file contains multiple studies and reports related to public health, and each study may have a different sample size. Without a specific study or report in question, it is not possible to provide a definitive answer regarding the sample size.

Age Range: The PDF file contains information related to influenza vaccination coverage for Nova Scotia residents aged six months of age and older ,[object Object],. Additionally, the study discusses influenza vaccine coverage in infants, which was found to have been steadily increasing throughout the pre-universal program period, with a large increase with the addition of the universal policy in 2010–2011 after which coverage declined for the remainder of the study period ,[object Object],.

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), Provider Training/Education, Nurse/Nurse Practitioner, CLASSROOM_SCHOOL, Teacher/Staff Training, PROFESSIONAL_CAREGIVER, Outreach (caregiver), Outreach (School Staff)

Intervention Description: Healthy and Ready to Learn is a targeted, school-based CHIP and Medicaid outreach initiative for identifying and enrolling eligible and uninsured children entering kindergarten in North Carolina’s highest need counties. School nurses and administrative staff attend regional trainings on how to use a required health assessment form, submitted at school entry, to identify uninsured children who could be eligible but are not enrolled in public insurance. Continuous community-based outreach (e.g., attending community events, providing outreach materials in various languages, contacting local organizations and leaders to help inform families about CHIP and Medicaid) is also utilized.

Intervention Results: With increased enrollment rates and well-child exam rates, findings demonstrate the potential benefits of using schools as a point of intervention in enrolling young children in public health insurance and as a source of trusted information for parents from low-income backgrounds. The initiative increased enrollment rates by 12.2% points and increased well-child exam rates by 8.6% points in the regression discontinuity design models, but not differences-in-differences, and did not significantly increase well-child visits. Findings demonstrate the potential benefits of using schools as a point of intervention in enrolling young children in public health insurance and as a source of trusted information for low-income parents.

Conclusion: Findings demonstrate the potential benefits of using schools as a point of intervention in enrolling young children in public health insurance and as a source of trusted information for low-income parents.

Study Design: Quasi-experimental difference-in-difference and regression discontinuity

Setting: Schools (Elementary schools in North Carolina)

Population of Focus: Uninsured kindergarten-aged children in high economic need counties in North Carolina

Data Source: Medicaid and CHIP administrative data, focus groups, key informant interviews

Sample Size: 300 children; 16 counties were selected as intervention sites that included 278 elementary schools in 22 districts; in the second year, expanded to 32 counties

Age Range: 4-6 years

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER, Expanded Insurance Coverage

Intervention Description: Examine the extent to which enrollment in the State Children's Health Insurance Program (SCHIP) affects access to care and service use in 10 states that account for over 60 percent of all SCHIP enrollees.

Intervention Results: Significantly higher percentage of adolescent well visits for CHIP enrollees vs children uninsured for at least 2 months in the prior year (p<.01)

Conclusion: Enrollment in SCHIP appears to be improving children's access to primary health care services, which in turn is causing parents to have greater peace of mind about meeting their children's needs.

Study Design: QE: non-equivalent control group

Setting: Ten states; California, Colorado, Florida, Illinois, Louisiana, Missouri, New Jersey, New York, North Carolina, and Texas

Population of Focus: Children enrolled in SCHIP for at least 5 months

Data Source: Surveys of 16,700 SCHIP enrollees

Sample Size: Established enrollees (n≈1747)6 Uninsured children (n≈758) N= children >13 years

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER, Expanded Insurance Coverage

Intervention Description: We assessed the impact of New York's State Children's Health Insurance Program on access, use, and quality of care for adolescents.

Intervention Results: Significantly higher number of preventive-care visits in the insured group (8.3% difference; p=.003)

Conclusion: Adolescents who enrolled in New York's State Children's Health Insurance Program experienced improved access, use, and quality of care. These findings suggest that the provision of health insurance can help to improve health care for adolescents.

Study Design: Time 1/time 2 (T1/T2) cohort design

Setting: New York City, the urban environs of New York City, upstate urban areas, and upstate rural regions

Population of Focus: Adolescents ages 12-18 in New York State

Data Source: Telephone interviews

Sample Size: N=1118 at baseline N=970 at follow-up

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER, Expanded Insurance Coverage, Cost-Sharing Requirements

Intervention Description: Affordable Care Act provisions implemented in 2010 required insurance plans to offer dependent coverage to people ages 19–25 and to provide targeted preventive services with zero cost sharing. These provisions both increased the percentage of young adults with any source of health insurance coverage and improved the generosity of coverage. We examined how these provisions affected use of the human papillomavirus (HPV) vaccine, which is among the most expensive of recommended vaccines, among young adult women.

Intervention Results: Using 2008–12 data from the National Health Interview Survey, we estimated that the 2010 policy implementation increased the likelihood of HPV vaccine initiation and completion by 7.7 and 5.8 percentage points, respectively, for women ages 19–25 relative to a control group of women age 18 or 26.

Conclusion: These estimates translate to approximately 1.1 million young women initiating and 854,000 young women completing the vaccine series.

Data Source: National Health Interview Survey

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

Intervention Description: We examined the effects of California's expansion on noncitizen children's uninsurance rates and sources of coverage, using data from the 2012-18 American Community Survey.

Intervention Results: California's expansion was associated with significant increases of about 9 and 12 percentage points in any coverage and public coverage, respectively. The estimated increase in any coverage translates to a 34 percent decline in the uninsurance rate relative to the preexpansion rate among noncitizen children (26 percent). Counties with an existing program to reduce children's uninsurance rates experienced an increase in coverage earlier than those without a program in effect before the statewide expansion.

Conclusion: The estimated increase in any coverage translates to a 34 percent decline in the uninsurance rate relative to the preexpansion rate among noncitizen children (26 percent). Counties with an existing program to reduce children's uninsurance rates experienced an increase in coverage earlier than those without a program in effect before the statewide expansion.

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

Intervention Description: We use the 2016 to 2020 National Survey of Children's Health (NSCH) to estimate the effects of Medicaid expansions through the Affordable Care Act (ACA) for parents on child health insurance coverage, parents' employment decisions due to child health, and family health-related financial well-being.

Intervention Results: We find that these expansions were associated with increases in children's public health insurance coverage by 5.5 percentage points and reductions in private coverage by 5 percentage points. We additionally find that parents were less likely to avoid changing jobs for health insurance reasons and children's medical expenses were less likely to exceed $1000. We find no evidence that the expansions affected children's dual coverage and uninsurance. Our estimates are robust to falsification and sensitivity analyzes.

Conclusion: Our findings also suggest that benefits on children's medical expenses are concentrated in the families with the greatest financial need.

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER, Expanded Insurance Coverage

Intervention Description: Data are from 64,565 youth (ages 0–17 years) participants in the 2011 to 2015 National Health Interview Survey. We conducted multivariate logistic regression analyses to determine how the period after national implementation of the ACA (years 2011–2013 vs years 2014–2015) was associated with health insurance coverage and utilization of health care services (well-child visits, having visited an emergency department, and having visited a physician, all in the past 12 months), and whether changes over the pre- and post-ACA periods varied according to race and Latino ethnicity.

Intervention Results: The post-ACA period was associated with improvements in insurance coverage and well-child visits for all youth. Latino youth had the largest absolute gain in insurance coverage; however, they continued to have the highest proportion of uninsurance post national ACA implementation. With regard to health care equity, non-Latino black youth were less likely to be uninsured and Latino youth had no significant improvements in insurance coverage relative to non-Latino white youth after national ACA implementation. Inequities in health care utilization for non-Latino black and Latino youth relative to non-Latino white youth did not improve.

Conclusion: Insurance coverage and well-child visits have significantly improved for all youth since passage of the ACA, but inequities persist, especially for Latino youth.

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER, Expanded Insurance Coverage

Intervention Description: No intervention

Intervention Results: In the January−February 2018 issue of Academic Pediatrics, we used 2011−2015 National Health Interview Survey (NHIS) data to assess changes in insurance coverage and well-child visits for youth and to study whether racial and ethnic inequities were affected by the ACA.1 We found that insurance coverage improved for all youth, and that black youth had the largest relative gain compared to white youth. On the other hand, Latino youth had the largest absolute gain but no improvement in health insurance inequities compared to white youth. For well-child visits, all youth improved post-ACA, but Latino youth had the lowest prevalence of well-child visits.

Conclusion: Of course, insurance coverage is just one piece of the access-to-care puzzle.4 Despite the increases in uninsurance, well-child visits continued to improve for all youth from 2011−2013-to-2016−2018. In 2011−2013, 81.2% of all youth had a well-child visit in the past year. This proportion increased to 83.9% in 2014−2015 and to 85.4% in 2016−2018. Black youth continue to have higher percentages of well-child visits than white and Latino youth, and Latino youth continue to have the lowest percentages. Since the publication of our study, a few other studies have been published showing the associations of the ACA with health care inequities for youth. Using 2011−2016 NHIS data, one study found that insurance coverage and utilization improved for Latino youth, but there were inequities according to youth’s Latino heritage.5 Among Latino youth, Mexican and Central/South American youth experienced the largest absolute increase in coverage, but they had the highest levels of uninsurance post-ACA, and inequities in well-child visits between Mexican heritage and white youth worsened.5 A study using 2014−2016 California Health Interview Survey data found that in the post-ACA period there were no racial/ethnic inequities in provider-related barriers to care (eg, trouble finding a doctor, child’s insurance not accepted by provider, child not being accepted as new patient) for children.6 However, another study using the same California data found that there were insurance-based inequities (eg, Medicaid, employer-based, and privately purchased) in provider availability, where parents of children with Medicaid or privately purchased coverage had over twice the odds of reporting at least one provider-related barrier.7 In 2019, the individual mandate penalty was changed to zero by the Internal Revenue Service due to the Tax Cuts and Jobs Act (2017) passed by Congress and signed by President Trump. Though the individual mandate still exists by law, there is no federal penalty for not having insurance coverage. We should pay close attention to future insurance enrollment decisions by parents in the absence of the federal mandate that could affect gains made in youth insurance coverage across all racial and ethnic groups of youth.

Setting: States

Population of Focus: Youth in the U.S.

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER, Expanded Insurance Coverage, HEALTH_CARE_PROVIDER_PRACTICE, Collaboration with Local Agencies (State), PROFESSIONAL_CAREGIVER, Outreach (caregiver), PATIENT_CONSUMER, Referrals, STATE, Mini Grants, Public Insurance (State)

Intervention Description: Small grants to community-based organizations have been shown to be effective in garnering the involvement of the local community in health promotion efforts. The Georgia Utilization Mini-grant Program leveraged modest funding and resources to promote community involvement to improve enrollment and utilization of Medicaid and CHIP services for children. It demonstrates how a state Medicaid agency can step outside its usual administrative role to play an important part in supporting local outreach and marketing efforts to promote Medicaid/CHIP enrollment and utilization.

Intervention Results: Funded community-based organizations improved utilization of children’s health services by developing innovative staffing patterns, creating new data systems for scheduling appointments and maintaining records, and forging new collaborative relationships to leverage financial support. Responses suggest that the program improved levels of enrollment, appointment-setting and referrals for social and other services. Common facilitators and barriers to success and ways to address them were also identified.

Conclusion: Elaboration on each of the facilitators of success led to the development of several recommendations as guidance for future outreach funding programs such as: staffing, data systems, collaboration and how to address incentives and barriers.

Study Design: Participatory approach

Setting: Community (Community-based organizations)

Population of Focus: Children enrolled in Medicaid and PeachCare

Data Source: Questionnaires, telephone interviews, one-on-one counseling, application assistance, home visits

Sample Size: 6 organizations

Age Range: Children; specific ages not stated

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER, Expanded Insurance Coverage, HEALTH_CARE_PROVIDER_PRACTICE, Collaboration with Local Agencies (State), Public Insurance (Health Care Provider/Practice), PROFESSIONAL_CAREGIVER, Outreach (caregiver), STATE, Data Collection System

Intervention Description: Florida Covering Kids & Families (FL-CKF) is dedicated to developing outreach methods for enrolling and retaining eligible children in the state’s CHIP. FL-CKP developed a strong data system that allows it to evaluate the effectiveness and success of statewide enrollment and retention efforts. Community and school outreach partners enter data each month on all completed CHIP applications via a secure interface, and data are then transmitted to the state. The data system is an outreach method for enrolling and retaining coverage; it can also monitor outcomes and provide feedback to community outreach partners. Organizations helping uninsured children apply for health insurance may benefit from creating data collection systems to monitor project efficacy and modify outreach and enrollment strategies for greater effectiveness.

Intervention Results: The highest number of application submissions were through outreach at a child’s school or childcare facility, through a community-based organization, or through targeted outreach events. However, even though those strategies resulted in the largest number of application, approval and denial rates show which of these strategies (through a CHIPRA grant partner site or government agency) yielded the highest enrollments. This information can be further stratified by individual project partner to show which strategies are working best in that region. The improved data collection system of Cycle II enables FL-CKF to better monitor the efforts of project partners by tracking monthly progress toward grant deliverable goals.

Conclusion: Organizations helping uninsured children apply for health insurance may benefit from creating data collection systems to monitor project efficacy and modify outreach and enrollment strategies for greater effectiveness.

Study Design: Evaluation assessment

Setting: Community (Community-based organizations and schools in Florida)

Population of Focus: Eligible children in Florida's CHIP

Data Source: Checkbox Survey Solutions data system

Sample Size: 502,866 children in Florida who are uninsured

Age Range: 0-17 years

Intervention Components (click on component to see a list of all articles that use that intervention): Medicaid Reform, Expanded Insurance Coverage,

Intervention Description: Passage of the Reproductive Health Equity Act, which included coverage for 60 days of postpartum care, including contraception, for the Emergency Medicaid population. In Oregon, this Act went into effect in April 2018.

Intervention Results: Before the policy change, 8.8% of Emergency Medicaid enrollees (1050 women) attended a postpartum visit. After the policy, 55.6% of Emergency Medicaid enrollees (1933 women) attended a postpartum visit. In our adjusted DID model, assuming parallel trends, the policy was associated with an increase in postpartum visit attendance of 40.6 percentage points (95% CI, 34.1-47.1 percentage points; P < .001). Assuming differential trends, the policy was associated with an increase in postpartum visit attendance of 47.9 percentage points (95% CI, 41.3-54.6 percentage points; P < .001)

Conclusion: These findings suggest that expanding Emergency Medicaid benefits to include postpartum care is associated with significant improvements in receipt of postpartum care and contraceptive use.

Study Design: Cohort study and difference-in-difference analysis

Setting: Birth settings where Medicaid is accepted

Population of Focus: Immigrant women eligible for emergency Medicaid in Oregon

Sample Size: 27,667 live births among 23,971 women

Age Range: <20--≥35

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER, Expanded Insurance Coverage

Intervention Description: The effect of expansion to near-universal health insurance coverage in Massachusetts on breast and cervical cancer screening. We use data from 2002 to 2010 to compare changes in receipt of mammograms and Pap tests in Massachusetts relative to other New England states.

Intervention Results: Significant increase in number of Pap tests (~5%) in difference in difference estimates from pre-reform to post-reform in Massachusetts

Conclusion: Overall, Massachusetts health reform appears to have increased breast and cervical cancer screening, particularly among low-income women. Our results suggest that reform was successful in promoting preventive care among targeted populations.

Study Design: QE: pretest-posttest non-equivalent control group

Setting: Massachusetts

Population of Focus: Women with no history of hysterectomy

Data Source: Behavioral Risk Factor Surveillance System

Sample Size: Baseline (n=34,874) Intervention (n=9,514); Control (n=25,360) Follow-up (n=31,018) Intervention (n=11,483); Control (n=19,535)

Age Range: 21-64

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), NATIONAL, Policy/Guideline (National)

Intervention Description: In 2006, Massachusetts passed major health reform legislation, including an individual mandate for adults (who were required to purchase insurance or face a penalty); Medicaid expansion (i.e., children’s eligibility for the state’s Medicaid-CHIP increased from 200 to 300% of the FPL and adult eligibility for Medicaid increased to 100% FPL), and minimum essential benefits for private insurance (e.g., coverage of basic specialty services, no co-pay or deductible for preventive care visits).

Intervention Results: Massachusetts health reform, the model for the ACA, reduced uninsurance and improved access to some types of care for children in the state. Expanding adult-oriented health access policies in MA was associated with a trend toward reduced uninsurance and improved access to specialty care for children overall at 5 years post-reform. For low-income children, health reform was associated with increased access to a personal doctor for children previously Medicaid-eligible and increased access to specialty care for children newly Medicaid-eligible.

Conclusion: Adult-oriented health reforms may have reduced uninsurance and improved access to some types of care for children in Massachusetts. Repealing the ACA may produce modest detriments for children.

Study Design: Quasi-experimental difference-in-difference

Setting: Policy (Data from 2003, 2007, and 2011-2012 waves of the National Survey of Children's Health)

Population of Focus: Families with children in Massachusetts

Data Source: National Survey of Children’s Health (NSCH

Sample Size: 5,760 children in the intervention group (MA), 28,183 children in the comparison group (other New England states)

Age Range: 0-17 years

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER, Expanded Insurance Coverage

Intervention Description: The evaluation of the Children's Health Insurance Program (CHIP) mandated by the CHIP Reauthorization Act of 2009 was conducted by Mathematica Policy Research and the Urban Institute. The evaluation included case studies in 10 states selected to provide geographic and demographic diversity, a nationwide telephone survey of state CHIP administrators, analysis of state eligibility and enrollment data, and a survey of 12,000 CHIP enrollees and disenrollees in the 10 study states, as well as 3,400 Medicaid enrollees and disenrollees in 3 of the states. The surveys collected information on health status, service utilization, and families' experiences with application, enrollment, and renewal processes. Other components included analysis of data from national surveys to examine coverage trends and Medicaid/CHIP participation rates.

Intervention Results: The evaluation found that CHIP, together with Medicaid, has significantly reduced uninsurance among low-income children, from 25% in 1997 to 13% in 2012, with coverage disparities narrowing for Hispanic children. Medicaid/CHIP participation rates increased from 82% in 2008 to 88% in 2012, with 21 states achieving rates above 90%. Relatively few CHIP enrollees had private coverage prior to enrollment, and direct substitution of CHIP for private coverage was estimated to be as low as 4%. The vast majority of children remained enrolled in CHIP for at least 28 months, and most disenrollees exited due to ineligibility. Compared to uninsured children, CHIP enrollees experienced better access to care, fewer unmet needs, and greater financial protection. While comparable to private coverage on many measures, CHIP enrollees had better access to dental care and much lower financial burden. Despite high rates of preventive visits, nearly 25% of enrollees had unmet needs and many were not receiving key

Conclusion: The evaluation demonstrated CHIP's success in expanding health insurance coverage for low-income children, improving their access to health care, and reducing financial burden and stress for their families across states with diverse program designs. Despite progress, further efforts are needed to cover the remaining 3.7 million uninsured children who are eligible for Medicaid or CHIP and improve retention and continuity of coverage. With the uncertain future of CHIP funding beyond 2015 and the changing health care landscape under the Affordable Care Act, the evaluation's insights on the value of CHIP and children's unique health care needs are particularly relevant for policymakers. Continuing to build on CHIP's accomplishments in providing affordable, comprehensive coverage will be critical to ensure that all low-income children can obtain the health care they need.

Study Design: QE: non-equivalent control group

Setting: Ten states: Alabama, California, Florida, Louisiana, Michigan, New York, Ohio, Texas, Utah, and Virginia

Population of Focus: Youth ages 13 and older enrolled in CHIP for at least 12 consecutive months

Data Source: 2013 Congressionally Mandated Survey of CHIP and Medicaid Enrollees and Disenrollees

Sample Size: Established enrollees (n≈2345) Uninsured children (n≈381) N=children >13 years

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Medicaid Reform, Expanded Insurance Coverage,

Intervention Description: Medicaid extended beyond 60 days postpartum for those with an income below 138% of the FPL

Intervention Results: Medicaid expansion in Arkansas was associated with a 27.8 (95% CI, 26.1-29.5) percentage point increase in continuous insurance coverage and an increase in outpatient visits of 0.9 (95% CI, 0.7-1.1) during the first 6 months postpartum, representing relative increases of 54.9% and 75.0%, respectively. Racial disparities in postpartum coverage decreased from 6.3 (95% CI, 3.9-8.7) percentage points before expansion to −2.0 (95% CI, −2.8 to −1.2) percentage points after expansion. However, disparities in outpatient care between Black and White individuals persisted after Medicaid expansion (preexpansion difference, 0.4 [95% CI, 0.2-0.6] visits; postexpansion difference, 0.5 [95% CI, 0.4-0.6] visits).

Conclusion: In this cohort study with a difference-in-differences analysis of 60 990 childbirths, Medicaid expansion was associated with higher rates of postpartum coverage and outpatient visits and lower racial and ethnic disparities in postpartum coverage. However, disparities in outpatient visits between Black and White individuals were unchanged. Additional policy approaches are needed to reduce racial and ethnic disparities in postpartum care.

Study Design: Quasi-experimental cohort study with a difference-in-differences analysis

Setting: Birth settings where Medicaid is accepted

Population of Focus: Low-income postpartum women eligible for expanded Medicaid

Sample Size: 60,990 childbirths

Age Range: 19-50

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), NATIONAL, Policy/Guideline (National), STATE, Prenatal Care Access

Intervention Description: Prenatal care is an important component of preventive health care with multigenerational consequences for women and their families. For low-income immigrant women, Emergency Medicaid, a federal safety net program for those poor enough to qualify for Medicaid but who cannot meet the citizenship requirements, covers the cost of a birth but not prenatal care or postpartum contraception. An “unborn child” option enacted in CHIP and CHIPRA gave states new options to provide prenatal care coverage with federal matching funds for extending coverage to immigrant children and pregnant women, regardless of their legal status or date of entry to the U.S. The study leveraged a natural experiment where unauthorized immigrant women eligible for Emergency Medicaid gained access to prenatal care coverage by the expansion of the Emergency Medicaid Plus program in Oregon.

Intervention Results: Expanding access to prenatal care coverage increased both utilization and quality of prenatal care, and women were more likely to receive adequate care and recommended preventive health services. After expansion of access to prenatal care, there was an increase in prenatal visits (7.2 more visits, 95% CI 6.46 to 7.98), receipt of adequate prenatal care (28% increased rate, CI 26 to 31), rates of diabetes screening (61% increased rate, CI 56 to 65) and fetal ultrasounds (74% increased rate, CI 72 to 77). Maternal access to prenatal care was also associated with an increased number of well-child visits (0.24 more visits, CI 0.07 to 0.41), increased rates of recommended screenings and vaccines, and reduced infant mortality (-1.04 per 1000, CI -1.45 to -0.62) and rates of extremely low birth weight (<1000g) (-1.5 per 1000, CI -2.58 to -0.53).

Conclusion: Our results provide evidence of increased utilization and improved health outcomes for unauthorized immigrants and their children who are United States citizens after introduction of prenatal care expansion in Oregon. This study contributes to the debate around reauthorization of the Children's Health Insurance Program in 2017.

Study Design: Quasi-experimental difference-in-difference

Setting: Policy (Oregon Health Authority)

Population of Focus: Pregnant low-income immigrant women and their infants

Data Source: Medical claims data from January 1, 2003 through October 1, 2015

Sample Size: 210,200 mothers and infants

Age Range: Pregnant women: 12-51 years; Infants: 0-1 years

Intervention Components (click on component to see a list of all articles that use that intervention): Medicaid Reform, Expanded Insurance Coverage,

Intervention Description: Expansion of Medicaid under the Families First Coronavirus Response Act (FFCRA) of 2020 which required that state Medicaid programs provide continuous coverage to enrollees through the end of the COVID-19 public health emergency (PHE)

Intervention Results: Within 90 days of delivery, postpartum services utilization was comparable Post- Families First Coronavirus Response Act (FFCRA) vs. Pre-FFCRA. After 90 days postpartum, however, Post-FFCRA utilization was 2-fold higher than Pre-FFCRA utilization (6.7 vs. 3.2%, respectively. The same patterns were observed when examining all outpatient services utilization. Although overall outpatient services utilization decreased after 90-days postpartum, Post-FFCRA utilization was 2–5-fold higher than Pre-FFCRA utilization through the end of the first-year postpartum, with 17.7% of Post-FFCRA women receiving outpatient care between 91- and 182-days and 17.9% between 183- and 365-days postpartum, vs. 3.4 and 8.8% for Pre-FFCRA women, respectively.

Conclusion: Our analysis demonstrates that the FFCRA's continuous coverage requirement is associated with a sustained increase in preventive services utilization throughout the first-year postpartum. Other benefits include increased utilization of contraceptive services, decreased incidence of short interval pregnancies, and increased utilization of MBH/SUD services.

Study Design: Retrospective cohort study and secondary analysis

Setting: Parkland Community Health Plan (a Texas Medicaid Health Maintenance Organization)

Population of Focus: Singleton postpartum women enrolled in Medicaid

Sample Size: 3,465 Pre-FFCRA and 5,411 Post-FFCRA deliveries

Age Range: 14-48

Intervention Components (click on component to see a list of all articles that use that intervention): Expanded Insurance Coverage, PAYER

Intervention Description: We compared rates of insurance disenrollment among patients with cancer who were DCP-eligible at age 19 to those who were not eligible at age 19.

Intervention Results: A total of 2,829 patients who turned 19 years of age in 2010-2012 were matched to patients who turned 19 in 2007-2009. Median time to disenrollment was 26 months for younger patients versus 22 months for older patients (hazard ratio [HR], 0.85; 95% CI, 0.80 to 0.90; P = .001). In 8,978 patients who turned 19 between 2001 and 2006, median time to disenrollment was 20 months among both younger and older patients (HR, 0.99; 95% CI, 0.94 to 1.03; P = .59). The difference between the recent cohort and the earlier control cohort was a 15% greater reduction in coverage loss (P < .0001), favoring those turning 19 after the DCP went into effect.

Conclusion: In the vulnerable population of adolescent and young adult cancer survivors, the ACA may have lowered the insurance dropout rate.

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), NATIONAL, Policy/Guideline (National)

Intervention Description: Dependent coverage expansion (DCE) policies on the state and federal level have been enacted to target the high rates of uninsurance and unique barriers to obtain coverage among adolescents and young adults (AYA). DCE, a component of the ACA, requires private insurance policies that cover dependents to offer coverage for policyholders’ children through age 26. Several states, including Massachusetts, New Hampshire, and Maine, adopted state DCE policies that extended dependent coverage, with the Massachusetts policy accompanied by other health reforms later incorporated into the ACA, including an individual mandate, a Medicaid expansion, creation of a health insurance exchange with subsidies, and prohibition of pre-existing condition exclusions. State and federal health reforms may modify the effects of a DCE by altering the coverage options and incentives for AYA.

Intervention Results: Findings suggest that an individual mandate and other reforms may enhance the effect of DCE in preventing loss of coverage among AYA. Implementation of DCE with other reforms was significantly associated with a 23% reduction in exit from dependent coverage among AYA compared to the reduction observed for DCE alone. Additionally, comprehensive reforms were associated with over two additional years of dependent coverage for the average AYA and a 33% increase in the odds of regaining dependent coverage after a prior loss. Findings suggest that an individual mandate and other reforms may enhance the effect of DCE in preventing loss of coverage among AYA. The joint effect of these policy levers is also associated with maintenance of dependent coverage until an older age and increased likelihood of regaining dependent coverage after an initial disenrollment. In addition to reductions in the odds of and time to dependent coverage exit, DCE was associated with further coverage gains for AYA in the form of regained dependent coverage.

Conclusion: Findings suggest that an individual mandate and other reforms may enhance the effect of DCE in preventing loss of coverage among AYA.

Study Design: Retrospective cohort with a pre- to post-comparison

Setting: Policy (Insurance consortium in 3 states: Massachusetts, Maine, and New Hampshire)

Population of Focus: Harvard Pilgrim Health Care members who were enrolled continuously as a dependent for at least 1 year between the ages of 16 and 18, from January 2000 to December 2012

Data Source: Enrollment and claims data from Harvard Pilgrim Health Care (HPHC), a large not-for-profit health plan with over 1 million members in commercial plans concentrated in Massachusetts, New Hampshire, and Maine

Sample Size: 131,542 individuals

Age Range: 16-18 years

Intervention Components (click on component to see a list of all articles that use that intervention): PAYER, Expanded Insurance Coverage

Intervention Description: The authors prospectively followed a representative panel of 16,204 individuals from the Oregon Medicaid lottery reservation list, collecting data before and after the Medicaid lottery drawings. The study panel was divided into 2 groups: a treatment group of individuals who were selected in the Medicaid lottery (6254 individuals) and a control group who were not (9950 individuals). The authors also created an elevated risk subpanel based on family cancer histories. One year after the lottery drawings, differences in cancer screening rates, preventive behaviors, and health status were compared between the study groups.

Intervention Results: Medicaid coverage resulted in significantly higher rates of several common cancer screenings, especially among women, as well as better primary care connections and self-reported health outcomes. There was little evidence found that acquiring Medicaid increased the adoption of preventive health behaviors that might reduce cancer risk.

Conclusion: Medicaid coverage did not appear to directly impact lifestyle choices that might reduce cancer risk, but it did provide access to important care and screenings that could help to detect cancers earlier. These findings could have long-term population health implications for states considering or pursuing Medicaid expansion. Cancer 2016;122:791-797. © 2015 American Cancer Society.

Study Design: Prospective RCT

Setting: Oregon

Population of Focus: Low-income, nondisabled, uninsured females who signed up for the Oregon Medicaid lottery reservation list7 Elevated risk subpanel: participants who reported, either for themselves or a close relative, a prior diagnosis of breast, ovarian, uterine, colon, or prostate cancer

Data Source: 1) Computerized administrative data 2) Written surveys distributed via mail

Sample Size: Total Panel at Baseline (n=4,023)8  Intervention (n=1,526)  Control (n=2,497) Elevated Risk Subpanel at Baseline (n=1,042)  Intervention (n=410) Control (n=632)

Age Range: 18-31