Find Established Evidence

NPM: 15: Continuous and Adequate Insurance
Intervention Components (click on component to see a list of all articles that use that intervention): NATIONAL, Policy/Guideline (National)
Intervention Description: Most children in low-income families were already eligible for public insurance through Medicaid or the Children's Health Insurance Program before the implementation of the Affordable Care Act (ACA). Increased coverage observed for these children since the ACA's implementation suggest that the legislation potentially had important spillover or "welcome mat" effects on the number of eligible children enrolled. This study used data from the 2013–15 American Community Survey to provide the first national-level (analytical) estimates of welcome-mat effects on children’s coverage post ACA.
Conclusion: We estimated that if all states had adopted the Medicaid expansion, an additional 200,000 low-income children would have gained coverage.

NPM: 15: Continuous and Adequate Insurance
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.
Primary Outcomes: Increase enrollment in public insurance for eligible children
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
Significant Findings: No
Setting: Schools (School districts in Van Buren County, Michigan)
Target Audience: Uninsured children
Data Source: Survey data
Sample Size: 8,999 children
Age Range: School-aged children

NPM: 15: Continuous and Adequate Insurance
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.
Primary Outcomes: Reduce out-of-pocket costs and enhance benefits adequacy for children and families
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
Significant Findings: No
Setting: Community (Coordinated Healthcare for Complex Kids (CHECK) program; Illinois Medicaid)
Target Audience: 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)

NPM: 15: Continuous and Adequate Insurance
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.
Primary Outcomes: Improve health insurance enrollment and renewal for children and self-efficacy for parents
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
Significant Findings: Yes
Setting: Community (Community-based organizations in Atlanta, Georgia)
Target Audience: Low-income young children and families
Data Source: Questionnaire data
Sample Size: 279 children
Age Range: 0-10 years

NPM: 15: Continuous and Adequate Insurance
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.
Primary Outcomes: Increase coverage for parents and children
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
Significant Findings: Yes
Setting: Policy (Oregon Medicaid expansion program)
Target Audience: 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

NPM: 15: Continuous and Adequate Insurance
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).
Primary Outcomes: Obtain health insurance for children from minority backgrounds; increase parental satisfaction with the process of obtaining insurance; increase access to quality health care for children from minority backgrounds; address unmet health care needs for children; increase parental satisfaction with quality of pediatric care; and reduce financial burden for parents
Conclusion: Parent mentors are highly effective in insuring uninsured Latino children and eliminating disparities.
Study Design: RCT
Significant Findings: Yes
Setting: Community (Communities in Dallas County, Texas with the highest proportions of uninsured and low-income minority children)
Target Audience: 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

NPM: 15: Continuous and Adequate Insurance
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).
Primary Outcomes: Obtain health insurance for children from minority backgrounds; increase parental satisfaction with the process of obtaining insurance; increase access to quality health care for children from minority backgrounds; address unmet health care needs for children; increase parental satisfaction with quality of pediatric care; and reduce financial burden for parents
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
Significant Findings: Yes
Setting: Community (Communities in Dallas County, Texas with the highest proportions of uninsured and low-income minority children)
Target Audience: 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

NPM: 15: Continuous and Adequate Insurance
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.
Primary Outcomes: Improve health insurance enrollment and renewal for children and self-efficacy for parents
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
Significant Findings: No
Setting: Community (New York City Department of Health and Mental Hygiene's Office of Health Insurance Services and the Early Intervention Program)
Target Audience: 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

NPM: 15: Continuous and Adequate Insurance
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.
Primary Outcomes: Increase coverage for parents and children
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
Significant Findings: No
Setting: Policy (States)
Target Audience: 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

NPM: 15: Continuous and Adequate Insurance
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.
Primary Outcomes: Keep families insured by assisting with public health insurance application processes
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
Significant Findings: No
Setting: Community (Community-health centers in Oregon)
Target Audience: 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

NPM: 15: Continuous and Adequate Insurance
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.
Primary Outcomes: Cover more services and defray costs
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
Significant Findings: No
Setting: Policy (CommonHealth, Massachusetts's Medicaid Buy-In program)
Target Audience: Parents and caregivers of Massachusetts children with disabilities enrolled in CommonHealth
Data Source: Survey data
Sample Size: 615 families
Age Range: 0-18 years

NPM: 15: Continuous and Adequate Insurance
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.
Primary Outcomes: Increase enrollment in public health insirance for eligible children
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
Significant Findings: Yes
Setting: Schools (Elementary schools in North Carolina)
Target Audience: 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

NPM: 15: Continuous and Adequate Insurance
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.
Primary Outcomes: Increase enrollment levels for children in Medicaid and CHIP; improve appointment setting and referrals for social and other services
Study Design: Participatory approach
Significant Findings: No
Setting: Community (Community-based organizations)
Target Audience: 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

NPM: 15: Continuous and Adequate Insurance
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.
Primary Outcomes: Increase the enrollment and retention of children eligible for public health insurance programs; quicken the turnaround time for application determination and enrollment; increase efficiency and cost effectiveness of outreach programs
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
Significant Findings: No
Setting: Community (Community-based organizations and schools in Florida)
Target Audience: 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

NPM: 15: Continuous and Adequate Insurance
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).
Primary Outcomes: Decrease uninsurance rates; improve access to care for children
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
Significant Findings: No
Setting: Policy (Data from 2003, 2007, and 2011-2012 waves of the National Survey of Children's Health)
Target Audience: 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

NPM: 15: Continuous and Adequate Insurance
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.
Primary Outcomes: Increase in adequate insurance for children (increase in coverage and care for women and their infants)
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
Significant Findings: Yes
Setting: Policy (Oregon Health Authority)
Target Audience: 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

NPM: 15: Continuous and Adequate Insurance
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.
Primary Outcomes: Reduce exit from dependent coverage; maintenance of health care 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
Significant Findings: Yes
Setting: Policy (Insurance consortium in 3 states: Massachusetts, Maine, and New Hampshire)
Target Audience: 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

NPM: 15: Continuous and Adequate Insurance
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.
Primary Outcomes: Increased spillover participation in SNAP (increased access to food) including any spillover participation affecting members of the household not targted by expansion such as children, and the poorest eligible households, due to Medicaid expansion
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
Significant Findings: Yes
Setting: Policy (States with Medicaid Expansion and SNAP)
Target Audience: Adults/families under 138 percent of the federal poverty level on Medicaid
Sample Size: 414,000 individuals
Age Range: N/A

NPM: 15: Continuous and Adequate Insurance
Intervention Components (click on component to see a list of all articles that use that intervention): STATE, Public Insurance (State), Enrollment Assistance
Intervention Description: There has been increasing interest among policy makers, navigators, and consumer organizations in developing novel outreach methods to address diverse barriers to enrollment. This study evaluates the impacts of personalized, live outbound telephone calls from service center representatives on enrollment in California's ACA Marketplace, Covered California, which accounts for 13.5% of national ACA Marketplace enrollment. The intervention targets consumers who had initiated the enrollment process by submitting an application but had yet to select a plan. Households in the study population were randomly assigned to one of two groups at the outset of the intervention period: a treatment group that was assigned to receive a phone call (hereafter referred to as an “outbound call”) from a service center representative and a control group that was assigned to not receive an outbound call. This intervention could address enrollment barriers such as lack of awareness of health insurance options, low health insurance literacy or computer literacy, preference for in-language assistance, and the time and cognitive costs of shifting through options. Those in the control group, similar to any other consumers, could contact the Covered California service center by calling the publicly available number that had been provided to them.
Primary Outcomes: Increased enrollment in Covered California health insurance due to personalized telephone outreach
Conclusion: The intervention provided a two-to-one return on investment. Yet absolute enrollment in the target population remained low; persistent enrollment barriers may have limited the intervention’s impact. These findings inform implementation of the American Rescue Plan Act of 2021, which expands eligibility for subsidized coverage.
Study Design: RCT
Significant Findings: Yes
Setting: Service Center for Marketplace Insurance Enrollment in California
Target Audience: Consumers who had applied but not selected a plan
Sample Size: 79,522 consumers (treatment group=55,519; control group=24,003)
Age Range: N/A

NPM: 15: Continuous and Adequate Insurance
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.
Primary Outcomes: Reduced insurance disruptions and coverage gaps due to Medicaid expansion
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
Significant Findings: Yes
Setting: Policy (Medicaid expansion in Massachusetts)
Target Audience: Young adults, 18-20 yr olds
Sample Size: 41,247 young adults
Age Range: 18-20 year olds