BEST PRACTICES TO IMPROVE TAKE-UP RATES IN HEALTH INSURANCE PROGRAMS

Final Report

Laura Summer and Jennifer Thompson
Georgetown University Health Policy Institute

Project Director: Elizabeth Hargrave, NORC at the University of Chicago
Project Consultant: Jack Hoadley, Georgetown University Health Policy Institute
Project Contributor: Bhumika Piya, NORC at the University of Chicago

August 18, 2008

Prepared for:
Office of the Assistant Secretary for Planning and Evaluation (ASPE)
U.S. Department of Health and Human Services (HHS)

This report was produced under the direction of Elizabeth Pham, Project Officer, Office of the Assistant Secretary for Planning and Evaluation (ASPE), Office of Health Policy. The findings and conclusions of this report are those of the authors and do not necessarily represent the views of ASPE or HHS.

This report is available on the Internet at:
http://aspe.hhs.gov/health/reports/08/bestpractices/report.html

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Table of Contents

Executive Summary

The number and percentage of Americans without health insurance has been increasing annually.  Between 2001 and 2006, the proportion of uninsured Americans increased from 14.1 percent to 15.8 percent.  Increases in the number and proportion of Americans who lack health coverage are due in part to the continued erosion of employer-sponsored health insurance.  The decline in coverage through the workplace has been paired with an increase in the proportion of Americans receiving coverage through public programs.  States have been particularly active over the last several years in expanding coverage through the Medicaid and SCHIP programs.  Three states also had enacted and implemented comprehensive health care reform and 14 others were developing comprehensive approaches to health care coverage as of August 2008.  On the federal level, President Bush introduced his Affordable Choices initiative in his January 2007 State of the Union address.
 
Even with expansions, participation rates in public programs targeting the uninsured are low; data from national surveys show that a substantial proportion of the individuals who lack health insurance coverage, particularly children, may have qualified for public programs.  Thus an examination of how to best implement outreach, enrollment, and retention efforts is warranted.  The findings are relevant for existing health insurance programs as well as new proposals to expand coverage, such as the Administration’s Affordable Choices initiative.

This report reviews the extensive literature on methods to improve take-up rates for health insurance coverage.  The purpose of this review is to take into account the strength of the evidence presented in studies regarding take-up.  This report, therefore, based its findings on previous studies that presented data rather than opinions.  The literature review also focused on articles pertaining to strategies to promote take-up, rather than to program participation barriers; and it is limited to interventions, rather than program design or policies that may affect take-up.  Although there is little causal evidence among the studies reviewed, some strong correlations are reported.  The discussion below presents conclusions from the available literature regarding five topics of particular interest: effective take-up strategies, cost-effectiveness of the strategies, effective strategies for special populations, relevant lessons for the Affordable Choices Initiative, and recommendations for future research. 

Effective strategies

Based on a careful analysis of all of the articles reviewed, two predominant findings emerge regarding efforts to promote successful take-up in health insurance programs.  The first is that individuals are more likely to enroll in insurance programs and maintain their coverage when extensive personal assistance, geared to the needs of the individual, is available.  The second major finding is that simpler enrollment and renewal processes increase the likelihood that individuals will obtain and retain coverage.  Studies of publicity campaigns find much weaker evidence of effectiveness.  In gauging the success of assistance efforts, the amount and type of assistance provided appears to be relevant as is the source of assistance.  Individuals are more likely to seek and accept help from organizations and individuals that they trust and that provide culturally or linguistically appropriate assistance. 

Cost-effectiveness of strategies to improve take-up

The literature reviewed does not include rigorous analysis of cost-effectiveness and the data on the cost-effectiveness of various strategies to increase take-up are not conclusive.  There is some evidence to suggest that well-targeted rather than broader efforts are more likely to be successful and cost-effective.  In discussions of findings, several researchers note that efforts to increase insurance coverage can be seen as good investments.  This is particularly true for health care providers, who stand to benefit from additional compensation from insurers if their patients are insured.  Also, the administrative savings associated with simplifying enrollment and renewal processes were documented in some articles.  Discussions also highlighted the issues that local initiatives to increase coverage may be difficult to sustain without a consistent source of support.

Strategies for special populations

The literature does not provide definitive information about strategies for take-up that are particularly effective for populations living in rural or urban areas.  There are indications from the literature that efforts to increase take-up are likely to be more successful if applicants and enrollees have the opportunity to receive assistance from trusted sources who speak the language they are most comfortable speaking and who are familiar with their culture.  There is also some evidence that publicity about programs will be more effective if other languages as well as English are used. 

Lessons for new coverage initiatives

One important lesson for any new initiative to increase health insurance coverage, such as the Affordable Choices initiative, is that outreach activities are crucial early on to introduce people to the new benefit, but publicity alone will not ensure that individuals seek and successfully enroll in coverage.  Also, simple enrollment and renewal processes will be helpful in ensuring that uninsured individuals obtain and keep coverage.  Furthermore, there is a good deal of evidence that without the availability of assistance, efforts to publicize programs or simplify enrollment will not be as effective as in efforts where assistance is available.  Although face-to-face meetings should not be required, all applicants and enrollees should have the option of receiving comprehensive assistance comprising not only assistance completing applications and obtaining documentation if it is required, but also providing follow-up.

If the nature of a new initiative differs in design from current insurance programs and options, then it will be important to provide adequate training about the new initiative as well as about existing programs and their relationship to the new initiative for those who may be assisting applicants.  Much of the literature on increasing take-up rates pertains to the low-income population.  If coverage expansions include individuals with higher incomes then it may be necessary to consider who the new target population would view as a trusted source for information and assistance.  Finally, with any new initiative there is a need to provide sufficient funding not only to help with the initial enrollment, but also to sustain activities to ensure that individuals who are eligible for coverage obtain and retain it successfully.

Recommendations for further research

The original intent of this project was not to develop recommendations about evaluation techniques, but in the course of reviewing resources for inclusion, the strengths and weaknesses of the research that has been done to date on this topic have become evident.  Therefore, this report includes some recommendations regarding future research to improve the availability and quality of information on the topic of take-up.  Specifically:   

Conclusion

Policy changes to expand health insurance coverage are more likely to succeed if they are accompanied by efforts to ensure that optimal take-up of benefits occurs.  This concept is generally recognized and there are many examples of activity on the federal, state, and local levels geared to increasing enrollment in public programs for children, families and the elderly.  Yet, program participation rates generally are lower than expected even as a substantial portion of the uninsured population is eligible for public insurance programs.  Thus, there is a need to understand how to best promote uptake.  A review of the literature on this topic indicates that individuals are more likely to enroll in insurance programs and maintain their coverage when extensive personal assistance is available.  Also, simpler enrollment and renewal processes are advantageous for both applicants and those who assist them, and contribute to higher enrollment rates.  More rigorous research is needed, however, to understand more about the efficacy and particularly the cost-effectiveness of different approaches.

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Introduction

The number and percentage of Americans without health insurance has been increasing annually.  There were 47 million uninsured Americans in 2006, compared to 39.8 million in 2001.  On a percentage basis, the number of uninsured Americans increased from 14.1 percent to 15.8 percent during the same time period.1
Among the uninsured, 36 percent come from households with incomes below 100 percent of the federal poverty level (FPL) and a total of 81 percent have incomes below 300 percent of FPL.  In 2006, some 20 percent of the non-elderly uninsured were younger than 19, young adults between the ages of 19 and 34 comprised 39 percent of the uninsured, 31 percent were aged 35 to 54 and 9 percent of the uninsured were in the age group 55 to 64.2 Insurance status also varies by race and ethnicity.  In 2006, more than one third of Hispanics – 36 percent – were uninsured, compared to 22 percent of blacks, 17 percent of Asians and 13 percent of whites.3

Among the non-elderly uninsured in America, 71 percent come from households with at least one full-time worker.  Another 11 percent come from households with at least one part-time worker.  Increases in the number and proportion of Americans who lack health coverage are due in part to the continued erosion of employer-sponsored health insurance; only 60 percent of firms offered health coverage to at least some employees in 2007, compared to 69 percent of firms in 2000.4 Suggested reasons for the decline include a shift of workers to smaller businesses, which are less likely to offer health insurance coverage than larger firms, and a shift of the cost of insurance from employers to employees, which may prompt some workers to drop coverage.5

The decline in coverage through the workplace has been paired with an increase in the proportion of Americans receiving coverage through public programs.  In 2001, almost 23 percent of children ages 18 and younger received coverage through Medicaid or the State Children’s Health Insurance Program (SCHIP); that percentage rose to 27 percent by 2006.  Employer-sponsored insurance, covered 64.4 percent of children in 2001; by 2006, the percentage had fallen to 59.7 percent.6

States have taken a number of actions to expand health care coverage for low-income children and some parents through the Medicaid and SCHIP programs by increasing income eligibility limits to levels above the minimum: 133 percent of FPL for pregnant women and children younger than age 6 and 100 percent of FPL for children ages 6 to 19.7 In 2007, forty-five states covered children in families with incomes of 200 percent FPL or higher.  At least 18 states have expanded their Medicaid or SCHIP programs to cover parents with incomes at 100 percent of FPL or higher.8 Some expected state expansions have not or will not occur, however, as two reauthorization bills that would have expanded the SCHIP were vetoed by President Bush in 2007.  Instead, Congress passed an 18-month extension of the program with some additional funding through March 2009.  In addition, an Administrative directive from August 2007 regarding SCHIP expansions affected policies and plans in states to offer coverage to children from families with incomes greater than 250 percent of FPL.9

Some states have moved beyond Medicaid and SCHIP expansions towards comprehensive health care reforms.  A review of state activity indicates that as of August 2008, three states had enacted and implemented comprehensive health care reform and 14 others were developing comprehensive approaches to health care coverage.10 In 2005, Maine implemented a subsidized health insurance program called DirigoChoice, which offers coverage to individuals, self-employed workers and small businesses.  Maine paired this program with an eligibility expansion of the state’s Medicaid program.11 The Massachusetts Health Care Reform plan has an individual mandate, which requires all adult residents to purchase health insurance.  At the same time, employers with 11 or more employees are required to offer coverage, or pay an annual “Fair Share” contribution.  Premium subsidies are available to low-income, uninsured individuals.12 Vermont established the Catamount Health Plan to provide coverage for uninsured adults.13

On the federal level, President Bush introduced his Affordable Choices initiative in his January 2007 State of the Union address.  Affordable Choices would provide states with the option to subsidize private health insurance to cover uninsured residents.  It would use redirected funds that are otherwise paid to hospitals and other health care institutions for care of the uninsured or underinsured.

For a new or existing program to be successful in improving health insurance coverage, the question of how to maximize take-up rates is a vital one to consider to ensure that all eligible uninsured targeted for the program are enrolled..  The topics of effective outreach, enrollment, and retention practices to improve take-up rates have received a great deal of attention over the past several years as states, the federal government, foundations, health plans, and community organizations have mounted campaigns and tried new procedures to increase enrollment for children and families in SCHIP and Medicaid programs.  Significant activity has also occurred with respect to the Medicare Savings Programs (MSP), the Medicare Part D program, and the Low-Income Subsidy for Part D.  These practices to improve take-up focus increasing program participation by reducing barriers to participation.

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Program participation

The emphasis on improving take-up rates or program participation is logical in considering any policy to expand health insurance coverage given that large numbers of individuals in the US are uninsured and that a substantial proportion of those who are uninsured is eligible for public health insurance programs but not enrolled.  There is ample evidence of low participation rates in public programs of all types.

Barriers to program participation

A substantial body of research that identifies barriers to participation has been published, though very little of it contains quantitative information.  Frequently cited barriers to participation by children and families in Medicaid and SCHIP include a lack of information (or incorrect information) about the benefit or how to enroll; the complexity of the application and renewal processes; and difficulty getting to public benefits offices.19 Reluctance to participate in public programs and the stigma associated with receiving public benefits are cited as barriers in some studies, but others indicate that stigma is not a factor in decisions about whether to participate in public programs.20

The importance of reaching individuals and assisting them with enrollment has long been recognized as part of efforts to overcome program participation barriers.  Also, there is acknowledgment that efforts to assure that the renewal process works well are essential to ensure that coverage initiatives will continue to be successful.  Research indicates that millions of children leave Medicaid and SCHIP each year and become uninsured despite their continued eligibility.  A large proportion of individuals who apply for public coverage have already participated in public programs.  Often the coverage gap is short – one to three months – suggesting that the gap is the result of administrative factors rather than changes in families’ circumstances during that period.  Still, those families are counted among the uninsured, and generally do not have coverage during the gaps.21

Over the years, the federal government has provided substantial funding for program outreach, which includes initiatives to publicize programs and streamline the application and enrollment processes.  President Bush’s budget for FY2009 included $450 million in outreach grants for the SCHIP program.22 Congress approved new funds for efforts to reach the population eligible for the Medicare Part D subsidy. 

Private organizations have also sponsored efforts to increase enrollment in public benefits programs.  The Robert Wood Johnson Foundation, for example, has supported a national multi-year campaign, the Covering Kids and Families initiative, focused on reducing the number of eligible but uninsured children and adults in the United States.  The State Solutions initiative, funded by the Robert Wood Johnson Foundation and the Commonwealth Fund, provided grants to states in an effort to improve enrollment in the Medicare Savings Programs.  State SCHIP and Medicaid programs have already exercised a number of options to make the application and renewal processes easier, though there is substantial variation among states.23

Policymakers have long recognized that to succeed, any new initiative to expand coverage must include strategies to promote take-up, but they need guidance to help them understand which strategies work best.  Despite the high level of activity on the part of some national, state, and local organizations to increase enrollment, few efforts have been accompanied by rigorous evaluations.  Little definitive information is available to indicate which methods for improving take-up are most effective or most cost-effective. 

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Purpose of this study

This report reviews the extensive literature on methods to improve take-up rates for health insurance coverage.  Originally conceived as a meta-analysis, the purpose of this review is to take into account the strength of the evidence presented in studies regarding take-up.  Thus, this report based its findings on previous studies that presented data rather than opinions.  The literature review also focused on articles pertaining to strategies to promote take-up rather than to program participation barriers, and it is limited to interventions rather than program design or policies that may affect take-up.  Although there is little causal evidence among the studies reviewed, some strong correlations are reported.  Many of the methods to improve take-up discussed in this report are appropriate for expansion policies and coverage approaches like the Affordable Choices Initiative.  The discussion below presents conclusions from the available literature regarding five topics of particular interest: effective take-up strategies, cost-effectiveness of the strategies, effective strategies for special populations, relevant lessons for new coverage program initiatives, and recommendations for future research. 

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Methods

This project makes a systematic assessment of the available literature on methods to overcome participation barriers and increase participation rates in health insurance programs.  The research seeks to answer four key questions:

Initially, the project was to feature a meta-analysis with the goal of providing evidence-based take-up best practices.  To that end, a literature review, which involved the creation of a database, was developed.  The methods used to construct the database and conduct the literature review are described in a preliminary report (see Appendix).24  The completed literature review catalogued resources on the basis of populations featured in the research, types of take-up strategies and activities studied, and the study methods used.  The resources gathered were then reviewed to determine which should be included in the next phase of the project and what form the next phase should take.  Based on the literature review findings, modifications to the meta-analysis approach were proposed for several reasons:

Past efforts to synthesize research on take-up strategies support the conclusions presented here.26 A systematic literature review was proposed and accepted as an alternative means to use the best available evidence to help answer the research questions.  This strategy-specific review examines the literature pertaining to each of four strategies for increasing take-up rates:

1) provide special assistance for applicants and enrollees
2) publicize benefits
3) simplify the enrollment process, and
4) simplify the renewal process. 

The methods used to construct the database ensure that it provides a rich source of reliable information.  Strong consideration was given in the initial review of the literature to the quality of the research.  The articles included in the database present evidence rather than opinions.  The collection of articles is focused on strategies to promote take-up, rather than on program participation barriers.  It is also limited to interventions, rather than program designs or policies that may affect take-up.  Although there is a dearth of causal evidence among the studies, some strong correlations are reported.

There are 84 articles in the database categorized according to whether they pertain primarily to the four strategies under review.  The most popular strategy examined in the articles is the provision of special assistance for applicants or enrollees followed by efforts to publicize benefits and then enrollment and renewal strategies.  A few of the articles provide general overviews of take-up strategies.  The results reported here are based on a review of the 84 articles in the original database.  Also, articles that are relevant to the topic were added to provide newly available information and some context as the report was prepared.  In reporting the findings, the type of data on which they are based is also reported to provide an indication of the relative strength of the findings.  In drawing conclusions, greater weight is given to the findings from more rigorous studies.  The report also includes recommendations regarding future research to improve the availability and quality of information on the topic of take-up.

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Findings 

Based on a careful analysis of all of the database articles, two predominant findings emerge regarding efforts to promote successful take-up in health insurance programs.  The first is that individuals are more likely to enroll in insurance programs and maintain their coverage when extensive personal assistance, geared to the needs of the individual, is available.  The second major finding is that simpler enrollment and renewal processes increase the likelihood that individuals will obtain and retain coverage.  Studies of publicity campaigns find much weaker evidence of effectiveness.  Each of these findings is discussed in detail below.

Although the cost-effectiveness of take-up strategies is very important to consider, the research on this topic is sparse.  The articles in the database do not include rigorous analysis of cost-effectiveness, but several do discuss cost.  The discussion below includes all of the references to cost in the articles.

Assistance: extensive and individual

Applicants and enrollees who receive assistance with the enrollment or renewal processes are more likely than others to obtain or retain coverage.  The types of organizations that provide enrollment assistance and the settings in which the assistance is provided vary.  Most commonly, state agencies, community organizations, and health care providers offer assistance.  Some providers are motivated to help uninsured patients sign up for health insurance to reduce the amount of uncompensated care that they provide.  Emergency rooms and community health centers are among the most common sites where individuals receive assistance with benefit applications.  Individuals with a variety of titles provide enrollment assistance.  For example, they may be called “enrollment facilitators, specialists or coordinators,” “caseworkers,” “outreach workers,” “intake workers,” or “community workers.”  In gauging the success of assistance efforts, the amount and type of assistance provided appears to be relevant as is the source of assistance.  Individuals are more likely to seek and accept help from organizations and individuals that they trust, and that provide culturally or linguistically appropriate assistance. 

Extensive assistance

The most successful assistance efforts guide individuals through the complete enrollment or renewal process.  They not only inform people about insurance options and make program applications available, but also assist in completing the application, gathering any documents that must accompany the application, help submit the application, and follow up with the individual to ensure that the application has been processed successfully in a timely manner or to provide more assistance if problems arise after the application has been submitted.27 Individual, one-on-one assistance is often involved. A number of the more rigorous studies in the database support these conclusions.

Other studies provide evidence based on enrollment data following interventions to provide extensive assistance, though it is not possible to determine from the studies what the results would have been without the intervention.  

In 2004, callers to the Health Coverage Tax Credits (HCTC) call center received extensive assistance with the HCTC application process from state officials in Virginia. (HCTC credits are available to some workers whose jobs have been displaced by international trade).  Officials contacted eligible individuals who had consented to receive help, confirmed the status of applications and trouble-shot issues with the IRS.  Ultimately, more than 90 percent

The approval rate for applications submitted is a different measure associated with assistance.  The Children’s Defense Fund (CDF) spearheaded a project in New York that was successful in that 97 percent of applications submitted to Medicaid and Child Health Plus were accepted.   There was no control group in this study, but the acceptance rate is high relative to other acceptance rates reported in the literature.  Some 25 volunteers from Columbia University were based at community-based organizations, including a Head Start, a health clinic, and several social service organizations.  They helped families complete applications and compile necessary documents.  The volunteers were certified to complete a Medicaid face-to-face interview, which is required in New York.  Families could complete the entire enrollment process at the volunteer site, which spared them a trip to the Medicaid office. The CDF reviewed applications for eligibility, completeness, and documentation before they were forwarded to Medicaid or SCHIP.  Volunteers also followed up with families with incomplete applications, either by phone or by mail.36

Finally, there is some evidence from the more descriptive literature to suggest that providing assistance is an important element of efforts to improve take-up. 

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Assistance from health care providers

The literature suggests that efforts to promote enrollment are more likely to be successful if those needing assistance feel comfortable working with those providing assistance.  Health care providers are generally also known and trusted entities.  In a 2002 national survey of recent SCHIP enrollees, respondents indicated that the most important sources of information about SCHIP were health care providers (22 percent), public agencies (20 percent), informal networks (18 percent), and children’s schools (17 percent).  A variety of sources were cited by the remaining 23 percent of respondents.41

There is strong evidence that the involvement of health care providers can have a positive impact on children’s enrollment in public insurance programs.  Families trust providers to give them good advice about health care.42 Also, the health care setting is a logical place to ask people about their health insurance coverage and to provide assistance.  Since families who do not have health insurance may go to the emergency room or to a local clinic to receive care, emergency departments and clinics are viewed as locations that provide an opportunity to enroll uninsured children.43

Approval rates for applications are less rigorous measures, but still give some information about the success of health care providers and health plans in assisting patients with their insurance applications.  Some 84 percent of applications were successful in an experiment involving enrollment workers stationed in a Michigan hospital emergency department. The workers identified uninsured children and collected information and consent from families for enrollment in public insurance programs. Researchers concluded that the program was reasonably efficient and cost-effective, as the reimbursements the hospital received from the public programs Medicaid and MIChild increased enough to accommodate the additional staffing costs of enrollment assistance.48

Enrollment data provide some information about other health-related efforts. A rural county in Alabama conducts annual school-based health fairs to identify uninsured children and then helps parents apply for public coverage.  Data compiled by the school system showed a 6.6 percent decrease in the number of uninsured children within the county school system over a six-year period compared to decreases of 3.5 percent and 3.1 percent in Alabama and the United States, respectively.49 

Findings from interviews, surveys, and case studies also provide some evidence of the efficacy of assistance from trusted sources.  Grady Hospital in Atlanta coordinated six staff members and Spanish-speaking volunteers to help patients apply for Medicaid, food stamps, and WIC.  They reported increased Medicaid enrollment among pregnant women, and that the time required for the application process decreased, from 45 days to 30 days.50

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Linguistically and culturally appropriate assistance

Enrollment and renewal efforts that are tailored to individuals’ needs are more likely to be successful.  The most common means of tailoring assistance is to try to accommodate populations whose first language is not English.  The desirability of one-on-one counseling, particularly for reaching groups that may be culturally different from the majority, is often cited. 

A controlled study from California shows that new monthly Medicaid enrollment increased among Asian and Hispanic children for families that had access to bilingual application assistors from existing community organizations, compared to children from families in the same neighborhood who did not have access to bilingual assistance.51

Observations from interviews, surveys, and case studies also provide some insight regarding linguistically and culturally appropriate assistance.

Surveys also show that applicants are more comfortable working with individuals who speak their language.  For example, a survey of Boston-area families enrolled in a state-sponsored health insurance program indicated that those with limited English proficiency were more likely than other enrolled families to have received assistance with enrollment.  Medical providers were an important source of information and assistance.56  A survey of enrollees in New York City’s Disaster Relief Medicaid, implemented in response to the 9/11 attacks, found broad satisfaction with that program’s accommodations for applicants with limited English skills.  Chinese and Hispanic applicants particularly appreciated that they were able to fill out the program’s application with someone who spoke their language.57

Generally, the focus of discussions about culturally appropriate methods is on particular racial or ethnic groups, but the literature suggests that it is important to consider the best way to reach other groups, including those that traditionally may not have participated in public programs. 

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Simplification of Applications and Renewals

The literature on strategies to improve take-up is full of examples of efforts to simplify the enrollment process for programs.  Since attempts to increase take-up rates cannot succeed if individuals who have coverage lose it, efforts to simplify the eligibility re-determination process for public programs are also needed to help keep people insured.  The strategies featured in the literature most often are:

Allow applicants and enrollees to make self-declarations about financial and other circumstances.  Recognizing that applicants and enrollees may have difficulty providing documents related to employment, identity, income or assets, some states allow

A structured examination of states’ experience with process changes in Medicaid and SCHIP concludes that certain other practices contribute to improvements in program retention as well.  They include: telephone renewals; telephone reminders to return renewal forms; making calls to verify financial information provided by the family; automated referrals from one program to the other; treating forwarding addresses as valid addresses and attempting to re-contact families; verifying addresses at each contact; listing county and worker names so that renewal cards can quickly be directed to the correct worker for follow-up; highlighting key lines in letters; and revising letters to make them more user-friendly.61

For the most part, rigorous evaluations of simplification strategies have not been conducted.  Generally, the literature on particular simplification efforts is descriptive, providing detail about the substantial amount of activity in states to streamline the enrollment and renewal processes. The strongest evidence that certain strategies and policies may be effective comes from program enrollment data.  It can be particularly difficult to analyze the relative efficacy of individual activities in situations where a multi-faceted approach is used to simplify enrollment and retention.  The types of available data and the findings related to comprehensive efforts and specific activities are discussed below. 

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Specific activities to simplify enrollment and renewal

A number of the studies in the database report data on enrollment, retention, and insurance rates to show that a particular intervention may have had an impact.  Most also compare the new measure to similar, previous, or expected measures.  Comparisons are helpful, though none of the comparisons presented here are strong enough to show definitively that a particular activity was the cause of the change in enrollment or coverage.  Findings for particular activities are summarized below.

Among the simplification strategies, those that allow self-declaration and use existing data for verification or to identify and enroll individuals are frequently studied.

 

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Methods to simplify renewal are also the subject of a number of studies. 

In an effort to encourage stable insurance coverage, most states have established 12-month enrollment periods rather than shorter periods and there is some information on the efficacy of this in the database.

On-line applications are common for private insurance, but less so in public programs.  There is some evidence that these may make enrollment easier for some individuals.

Finally, there is some discussion about simplifying applications and the application process in the descriptive literature. 

Comprehensive efforts to simplify enrollment and renewal

A variety of policy changes or activities can be used to simplify enrollment and renewal.  Each deserves consideration, but it is important to note that if implemented individually they may not make a significant difference in enrollment.  For example, a multivariate analysis of the March 2001 Current Population Study concluded that on its own, elimination of the face-to-face interview did not appear to influence enrollment.83  

Enrollment and insurance coverage data suggest that each of the initiatives described below, using a combination of activities, had a positive impact on program participation. 

Some researchers report that when applications are completed without assistance, they are more likely to contain errors or to lack necessary documentation.  This suggests that alternate methods of submitting applications should ideally be paired with simpler applications and adequate assistance for enrollees.  Descriptive data from several states support this point.

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Publicity

Prior research suggests that many eligible families simply do not know about health insurance programs or are not aware that they may qualify for benefits.  To remedy this, advertising for health insurance programs has included comprehensive media campaigns, television, radio, or print media, and advertisements on public transit or billboards.  Another approach is the use of products – objects printed with a program’s information that can be easily distributed, like fans in churches, emery boards at nail salons, and tray liners at fast food restaurants.  Health fairs and information sessions are common places that people learn about insurance programs.  It is also interesting to note that while publicity can be helpful, “word of mouth” is a very common means by which families hear about the Medicaid and SCHIP programs.92

Enrollment data are reported for several studied related to providing publicity.

There is some evidence that publicity about programs will be more effective if information is available in languages other than English. 

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Cost-effectiveness of take-up strategies

Measures of cost-effectiveness are of particular interest for this project, but very little of the available research pertains to the cost-effectiveness of take-up strategies and none of the research includes rigorous analysis of cost-effectiveness.  Every article in the database was examined for any information related to the cost of outreach, enrollment, or retention activities.

A few articles discussed outreach activities in the context of making an investment to increase enrollment.

There are some indications in the literature of the cost of providing various types of enrollment assistance.  It is important to note, however, that these figures are likely associated with assistance provided using a variety of approaches in many settings to differing numbers and types of people.  Therefore, while they can be informative in a general way, they are not comparable and may not be relevant for new programs.

Discussions of the cost of different strategies conclude that providing one-on-one assistance is expensive relative to other activities because of the labor intensity, but these are not accompanied by assessments of the relative effectiveness of methods.108 Well-targeted efforts are more likely to be successful and cost-effective.  Preliminary research designed to identify the population to be reached and to determine what portion of a target population needs coverage is essential to help assure that limited resources are spent most effectively.109

Findings from the literature illustrate the importance of understanding the particular circumstances associated with cost estimates.  For example, very different outcomes were reported for two projects that provided enrollment assistance in New York City.  In one study of enrollment facilitators, researchers concluded that facilitators located in high-traffic areas could potentially assist four to five families per day.  At that rate, the cost per completed application was estimated to be approximately $35.110  But the cost per application was much higher for another effort that trained student volunteers to help families enroll in public coverage in New York because only a small number of applications per volunteer was submitted.111

Administrative savings associated with simplifying the enrollment and renewal processes are discussed in a few articles.  For example, an effort in Oregon to reduce the number of application steps from 72 to 16 cut the average number of days to process an application and considerable savings were associated with the reduced need to pay eligibility workers for overtime.112 Policy changes to simplify the renewal process for the Medicare Savings Programs in Louisiana also produced administrative savings.113

One other consideration related to cost is whether initiatives can be sustained and whether they can be implemented in a less costly manner.  A review of five local access initiatives concludes that without outside support, local projects are difficult to sustain.114 Activities such as translating applications into other languages can be expensive, especially for states where multiple languages are needed.115 The research suggests that in some instances the federal government may be able to provide assistance in a less costly manner because of economies of scale associated with sponsoring a single activity – such as the translation of program materials – that can be used by large numbers of people across the country.

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Answers to research questions

Findings from the literature form the basis for responses to four key research questions pertaining to methods that have been or could be used to overcome enrollment barriers and increase participation rates in health insurance programs. 

Effective strategies

What types of outreach, enrollment and retention strategies have proved most effective in ensuring that uninsured individuals have public or private coverage?
Based on the research to date, the strategy that has proved most effective is to provide assistance with every aspect of the enrollment and renewal process for those who need it.  One-on-one assistors can help solve particular problems if they arise.  Assistance geared to certain populations – such as assistance in languages other than English – is likely to be most effective.  Also, applicants and enrollees are more likely to seek and use assistance from sources they trust. Examples in the literature of trusted sources include members of community-based organizations, health care providers, school officials, nurses, or coaches, and members of the religious community.  Strategies to simplifying enrollment and renewal processes are also essential if efforts to help individuals obtain and retain coverage are to succeed.  Findings from the literature indicate that using a combination of strategies – activities to publicize benefits, to simplify the enrollment and renewal processes, and to provide assistance can be very effective.  Ideally, several types of complementary activities can be undertaken.  The key point, however, is that without the availability of assistance for applicants and enrollees, other activities are less effective. 

Cost-effectiveness of strategies to improve take up

Which outreach, enrollment and retention strategies are particularly cost-effective?  Data on the cost-effectiveness of various strategies to increase take-up are not conclusive.  In fact, very little definitive research is available on this topic.  There is some evidence to suggest that well-targeted efforts are more likely to be successful and cost-effective.  Some estimates of the cost of various activities do appear in the research literature, but because each effort is so different in terms of magnitude as well as how and where it was implemented, who it targeted, how long it lasted, and at what point in the program it occurred, it is not possible to compare or generalize from these data. 

In discussions of findings, several researchers note that efforts to increase insurance coverage can be seen as good investments.  This is particularly true for health care providers, who stand to benefit from additional compensation from insurers if their patients are insured.  Also, the administrative savings associated with simplifying enrollment and renewal processes were documented in some articles.  Discussions also highlight the issues that local initiatives to increase coverage may be difficult to sustain without a consistent source of support.  Economies of scale can be achieved when certain activities, such as translating materials into other languages, can be accomplished on the federal or state level.  

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Strategies for special populations

Which outreach, enrollment and retention strategies are particularly effective for special populations (those living in urban and rural areas, those whose first language is not English, and those whose cultural background or practices are different from the majority of program participants)?   The literature does not provide definitive information about strategies for take-up that are particularly effective for populations living in rural or urban areas.  Given the findings of this report, rural areas may face challenges related to finding economies of scale in their efforts to increase take up.  One-on-one assistance may be more costly to provide in less populated areas.

There are indications from the literature about the importance of making accommodations for individuals whose first language is not English or whose cultural background or practices are different from the majority of program participants.  Specifically, applicants and enrollees should have the opportunity to receive assistance from trusted sources who speak the language they are most comfortable speaking and who are familiar with their culture.  There is also some evidence that publicity about programs will be more effective if other languages as well as English are used.  Findings from the literature indicate that one-on-one assistance is particularly effective in helping individuals whose first language is not English.

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Lessons for the new coverage program initiatives

What lessons are particularly important to consider with regard to new programs to expand coverage, such as the Affordable Choices Initiative?  One important lesson for the Affordable Choices Initiative or any new initiative or program to increase health insurance coverage is that outreach activities are crucial early on to introduce people to the new benefit, but that publicity alone will not ensure that individuals seek and successfully enroll in coverage. 

The simpler the enrollment process, the more likely that uninsured individuals will complete the process successfully.  Strategies to achieve a simple process include allowing individuals to make self-declarations about their circumstances and using data to which the government has access to verify that information or using the existing data to make determinations about eligibility.  Allowing individuals to apply using a variety of methods including mail-in, telephone and on-line applications, which do not involve a face-to-face meeting, is another recommendation to increase enrollment.  These recommendations also apply to the renewal process.  Establishing a 12-month eligibility period is another recommendation to simplify renewal.  A review of the literature suggests that the best approach is to implement all of these policies, rather than just selected policies for simplification.  Additionally, if feasible, automatic enrollment is the simplest and likely most effective strategy for take-up. 

There is a good deal of evidence that without the availability of assistance, efforts to publicize programs or simplify enrollment will not be as effective as they could be.  One-on-one assistance appears to be most effective.  Although face-to-face meetings should not be required, all applicants and enrollees should have the option of receiving assistance if the goal is to achieve maximum take-up.  The assistance should be comprehensive, comprising not only assistance completing applications and obtaining documentation if it is required, but also providing follow-up to determine if enrollment occurred and to provide further assistance if needed.

If the nature of a new initiative differs in design from current insurance programs and options then it will be important to provide adequate training about the new initiative as well as about existing programs and their relationship to the new initiative for those who may be assisting applicants.  For example, implementation of a the premium assistance program in Massachusetts posed challenges for community-based outreach workers because they were less familiar with private health insurance than with traditional Medicaid and initially experienced difficulty in explaining the premium subsidy to potentially eligible low-income workers.116

Another lesson is that both outreach and assistance should be tailored to the target population.  This is especially important if individuals who are linguistically or culturally different from the majority are to be successfully enrolled.  Much of the literature on increasing take-up rates pertains to the low-income population.  If coverage expansions include individuals with higher incomes then it may be necessary to consider who the new target population would view as a trusted source for information and assistance. 

Finally, with any new initiative there is a need to provide sufficient funding not only to help with the initial enrollment, but also to sustain activities to ensure that individuals who are eligible for coverage obtain and retain it successfully.

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Recommendations for further research

Although this project was not originally designed to develop recommendations about evaluation techniques, findings from this as well as previous efforts to synthesize existing research on take-up strategies indicate that there is a need for more rigorous research to better inform policy in this area.  The literature review revealed strengths and weaknesses of the research that has been done to date on this topic.  Therefore, this report includes some recommendations regarding future research to improve the availability and quality of information on the topic of take-up. 

Conduct more quantitative research

The first recommendation is for more quantitative research.  Although a great deal has been written about outreach and enrollment efforts, the majority of the literature is descriptive in nature.  As noted above, the existing literature provides a good deal of information and the basis for some strong conclusions about increasing take-up, but it is not possible to draw conclusions about cause and effect.    

Use meaningful outcomes to measure success

If the goal of an intervention is to increase take-up, then the meaningful outcome is whether a change in enrollment occurs.  Other measures such as the number of individuals reached, the number assisted, the number potentially eligible for benefits, the number of applications distributed or filed, or the approval rates for applications may provide useful information and lead to program improvements, but these are process measures.  The outcome measure of real interest is the number of individuals that actually enroll in a health insurance program as a consequence of an intervention.  As noted above, enrollment is a function both of the number of people obtaining coverage and the number losing it.  Thus, both measures should be examined to get the most complete understanding of the impact of particular interventions on enrollment.

If enrollment data are not available, health insurance coverage data may also be examined, but generally it is not possible to find coverage data specific to the population eligible for particular programs or benefits.  These data are consequently not as reliable for the purpose of measuring outcomes.

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Make meaningful comparisons

Simply measuring enrollment changes is not sufficient to show whether an intervention has been successful or not.  To determine that, it is necessary to compare what happened because of the intervention with what would have happened otherwise.  In a classic experiment, the comparison would be between one group exposed to the intervention and another comparable group that is not exposed.  Even if it is not possible or practical to conduct such an experiment it should be possible to make meaningful comparisons.  Baseline data that show usual enrollment patterns prior to an intervention can be compared to patterns later.  Actual enrollment can be compared to the expected enrollment.  Or, enrollment patterns for comparable counties or other regions or for comparable groups may be compared if an intervention is conducted for one group but not another. 

Take other factors into account

The goal in assessing the effectiveness of an intervention is to determine whether changes in policy or practice have an effect on enrollment or coverage.  Other factors such as economic conditions may have an effect on the number of individuals seeking health care coverage, however.  Changes in unrelated program regulations or data systems also may affect enrollment.  These factors sometimes may be beyond the control of those who implement or measure interventions to improve take-up.  At the very least factors that may affect coverage should be acknowledged.  If possible they should be taken into account in measuring impact. 

Include measures of cost-effectiveness

As noted earlier, there is a dearth of information about the cost-effectiveness of various interventions to increase take-up.  This is an area of research that deserves much more attention. 

It is important to measure the cost of an intervention, but costs alone are not meaningful without information about the outcome associated with the intervention.  For example, discussions in the literature often note that one-on-one counseling is expensive relative to other strategies to increase take-up.  But more appropriate than comparing the relative cost of interventions is comparing the cost per enrolled individual associated with each intervention.  As noted above, the appropriate enrollment outcome measure is the number enrolled above the number ordinarily expected to enroll. 

In calculating costs, any savings that may be associated with an intervention, such as administrative savings associated with simplifying an application or renewal process should be considered along with new costs associated with the intervention.  Another meaningful comparison for providers is the cost of an intervention relative to actual or anticipated increases in revenue from insurance payments.  Finally, a more difficult, but potentially useful, comparison is the cost of interventions relative to actual or anticipated changes in overall health care spending for newly covered individuals who may then have greater access to preventive, primary, and other types of care.

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Invest in simple, routine measurement

Health insurance programs that routinely measure the number of individuals who enter and leave the program and the proportion of enrollees that successfully renew coverage each month have an advantage in that they have baseline measures to use in evaluating the impact of a new intervention.  Thus, the number of new enrollments that occur during a particular promotional effort or following a policy change designed to promote enrollment can be compared with the number that usually occur to help gauge the impact of the new efforts.  Similarly, policies that may have a negative effect on coverage can be more easily identified if baseline data are available.

Conclusion

Policy changes to expand health insurance coverage are more likely to succeed if they are accompanied by efforts to ensure that optimal take-up of benefits occurs.  This concept is generally recognized and there are many examples of activity on the federal, state, and local levels geared to increasing enrollment in public programs for children, families and the elderly.  Yet, program participation rates generally are lower than expected even as a substantial portion of the uninsured population is eligible for public insurance programs.  Thus, there is a need to understand how to best promote uptake.  A review of the literature on this topic indicates that individuals are more likely to enroll in insurance programs and maintain their coverage when extensive personal assistance is available.  Also, simpler enrollment and renewal processes are advantageous for both applicants and those who assist them, and contribute to higher enrollment rates.  More rigorous research is needed, however, to understand more about the efficacy and particularly the cost-effectiveness of different approaches.

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Footnotes

  1. More Americans, Including More Children, Now Lack Health Insurance. (Washington, DC: Center on Budget and Policy Priorities, August 31, 2007).
  2. Health Insurance Coverage in America, 2006. (Washington, DC: The Henry J. Kaiser Family Foundation, 2008).
  3. DeNavas-Walt, Carmen, Bernadette Proctor and Jessica Smith.  Income, Poverty and Health Insurance Coverage in the United States: 2006. (Washington, DC: U.S. Census Bureau, August 2007).
  4. The Uninsured; A Primer. (Washington, DC: The Henry J. Kaiser Family Foundation, October 2007), 2.
  5. Holahan, John. “Changes in Employer-Sponsored Health Insurance Coverage.” Snapshots of America’s Families III, no. 9.  (Washington, DC: Urban Institute, September 2003).
  6. More Americans, including More Children, Now Lack Health Insurance. (Washington, DC: Center on Budget and Policy Priorities, August 31, 2007).
  7. Medicaid At-A-Glance 2005. (Washington, DC: The Centers for Medicare and Medicaid Services, 2005); Medicaid income eligibility for parents/guardians varies by employment status, and is lower than income eligibility levels for children.  The Henry J. Kaiser Family Foundation,  StateHealthFacts.org. “Income Eligibility for Parents Applying for Medicaid by Annual Income as a Percent of Federal Poverty Level (FPL), 2008.” (Accessed 12 August 2009, http://statehealthfacts.org/comparetable.jsp?ind=205&cat=4).
  8. Cohen Ross, Donna, Aleya Horn and Caryn Marks.  Health Coverage for Children and Families in Medicaid and SCHIP. (Washington, DC: The Kaiser Commission on Medicaid and the Uninsured, January 2008).
  9. Orszag, Peter R. “Covering Uninsured Children in the State Children’s Health Insurance Program.” Testimony before the Subcommittee on Health Care, Committee on Finance, United States Senate, May 15, 2008.
  10. "States Moving Toward Comprehensive Health Care Reform," The Kaiser Commission on Medicaid and the Uninsured, 11 August 2008, http://kff.org/uninsured/kcmu_statehealthreform.cfm
  11. Lipson, Debra J., James M. Verdier and Lynn Quincy.  Leading the Way: Maine’s Initial Experience in Expanding Coverage Through Dirigo Health Reforms. (New York, NY: The Commonwealth Fund, December 2007).
  12. Massachusetts Health Care Reform Plan: An Update. (Washington, DC: The Kaiser Commission on Medicaid and the Uninsured, June 2007).
  13. States Moving Toward Comprehensive Health Care Reform," The Kaiser Commission on Medicaid and the Uninsured, 11 August 2008, http://kff.org/uninsured/kcmu_statehealthreform.cfm
  14. Lisa Dubay, John Holahan, and Allison Cook, “The Uninsured and the Affordability of Health Insurance Coverage,” Health Affairs 26, No. 1 (2007): w22-w30.
  15. U.S. General Accounting Office, Low-Income Medicare Beneficiaries: Further Outreach and Administrative Simplification Could Increase Enrollment (Washington, DC: U.S. General Accounting Office, April 1999). GAO/HEHS 99-61.
  16. Congressional Budget Office, A Detailed Description of CBO’s Cost Estimate for the Medicare Prescription Drug Benefit (Washington, DC: Congressional Budget Office, July 2004).
  17. Centers for Medicare and Medicaid Services, “Medicare Prescription Benefit’s Projected Costs Continue to Drop,” press release, January 31, 2008.
  18. U.S. Government Accountability Office, Means-Tested Programs: Information on Program Access Can Be an Important Management Tool (Washington, DC: U.S. Government Accountability Office, April 2005). GOA-05-221.
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  24. Analysis of Best Practices for Take-Up Rates, Preliminary Literature Review, submitted to ASPE January 31, 2008.
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  27. Sonja Hoover, Galina Khatusky and Susan Haber.  Evaluation of the Process and Impact of State Outreach and Enrollment Programs for Dual Eligibles (Washington, DC:Centers for Medicaid and Medicare Services, November 2002).
  28. Glenn Flores, Milagros Abreu and Christine Chaisson et al, “A Randomized, Controlled Trial of the Effectiveness of Community-based Case Management in Insuring Uninsured Latino Children,” Pediatrics 116, No. 6 (2005): 1433-1441.
  29. Inez Sieben, Terry J. Rosenberg and Yoly Bazile,  The Role of WIC Centers and Small Businesses in Enrolling Uninsured Children in Medicaid and Child Health Plus (New York: The Commonwealth Fund, March 2000).
  30. Lisa Alecxih, Mary Farrell, Sam Ankrah and BrieAnne Olearczyk, Results from the SSA Buy-In Demonstration.  Prepared for the Social Security Administration (Falls Church, VA: The Lewin Group, October 4, 2001).
  31. Karen Minyard, Deborah Chollet, Laurie Felland et al, Lessons from Local Access Initiatives: Contributions and Challenges (New York: The Commonwealth Fund, August 2007).
  32. Embry Howell, Christopher Trenholm, Kathy Gifford and Bridget Lavin, Covering Kids and Families Evaluation.  Case Study of Virginia: Exploring Medicaid and SCHIP Enrollment Trends and Their Links to Policy and Practice.  (Princeton, NJ: Mathematica Policy Research, Inc., July 2006).
  33. Gerry Fairbrother, Jennifer Stuber, Melinda Dutton et al, “An Examination of Enrollment of Children in Public Health Insurance in New York City Through Facilitated Enrollment,” Journal of Urban Health 81, No. 2 (2004): 191-205.
  34. Esther M. Forti and Marilynn Koerber, “An Outreach Intervention for Older Rural African Americans,” The Journal of Rural Health 18, No. 3 (2002): 407-415.
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  36. Melinda Dutton, Sarah Katz and Alison Pennington, Using Community Groups and Student Volunteers to Enroll Uninsured Children in Medicaid and Child Health Plus (New York: The Commonwealth Fund, March 2000).
  37. Wooldridge et al, Congressionally Mandated Evaluation of the State Children’s Health Insurance Program.
  38. Kristen Kiefer, Marisa Scala-Foley, Jay Greenberg, Kimberley Fox and Bob Power,  Why Inreach Makes good Business Sense: The Case for Medicare Advantage and Part D Plans  (New Brunswick, NJ: The Rutgers Center for State Health Policy, September 2007).
  39. Anne-Marie Brown and Greer Glazer, “Enrollment Success in State Children’s Health Insurance Program After Free Clinic Referral,Journal of Pediatric Health Care 18, No. 3 (2004): 145-148.
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  41. Wooldridge et al, Congressionally Mandated Evaluation of the State Children’s Health Insurance Program. 
  42. Andrew W. Dick, Jonathan D. Klein and Laura P. Shone et al., “The Evolution of the State Children’s Health Insurance Program in New York: Changing Program Features and Enrollment,” Pediatrics 112, No. 6 (2003): e542-e550.
  43. Susan M. Nedza, Deborah Mulligan-Smith and Russell Harris, “Emergency Departments and Uninsured Children: An Enrollment Opportunity,” Annals of Emergency Medicine 36, No. 3 (2000): 240-242.
  44. Amy J. Davidoff and Bowen Garrett, “Determinants of Public and Private Insurance Enrollment Among Medicaid-Eligible Children,” Medical Care 39, No. 6 (2001): 523-535.
  45. Benjamin D. Sommers, “Protecting Low-Income Children’s Access to Care: Are Physician Visits Associated with Reduced Patient Drop-Out from Medicaid and the Children’s Health Insurance Program?” Pediatrics 118, No. 1 (2006): e36-e42.
  46. The remainder could not be contacted or were unsure of their insurance status; their successful enrollment was confirmed with state agencies.  James A. Gordon and Terry A. DuPuie, “Child Health Insurance Outreach through the Emergency Department: A Pilot Study,” Academic Emergency Medicine 8, No. 11 (2001): 1088-1090.
  47. James A. Gordon, Jennifer A. Emond and Carlos A. Carmago, “The State Children’s Health Insurance Program: A Multicenter Trial of Outreach Through the Emergency Department,” American Journal of Public Health 95, No. 2 (2005): 250-253.
  48. Prashant Mahajan, Rachel Stanley, and Kevin W. Ross et al., “Evaluation of an Emergency Department-Based Enrollment Program for Uninsured Children,” Annals of Emergency Medicine 45, No. 3 (2005): 245-250.
  49. Bronwen Lichtenstein, Amit K. Sharma and John R. Wheat, “Health Inequity.  The Plight of Uninsured Children in a Rural Alabama County and the Plan to Cure It,” Family & Community Health 28, No. 2 (2005): 156-167.
  50. Dennis Andrulis,  Tamar Bauer and Sarah Hopkins.  Strategies to Increase Enrollment in Children’s Health Insurance Programs  (New York: The New York Forum for Child Health, January 1999).
  51. Anna Aizer, “Low Take-Up in Medicaid: Does Outreach Matter and for Whom?  American Economic Review 93, No. 2 (2003): 238-241.
  52. Embry Howell and Brigette Courtot, Covering Kids and Families Evaluation. Targeting Special Populations in the CKF Program: Lessons from Site Visits to Ten States (Princeton, NJ: Mathematica Policy Research, Inc., March 29, 2004).
  53. Kathleen M. Mathieson and Jennie J. Kronenfeld,  2003.  “Barriers to Enrollment and Successful Outreach Strategies in CHIP: Reflections on the Arizona Experience,” Journal of Health Care for the Poor and Underserved 14, No. 4 (2003): 465-477; Xochitl Castaneda, Zoe C. Clayson, Tom Rundall, Liane Dong, and Margo Sercaz, “Promising Outreach Practices: Enrolling Low-Income Children in Health Insurance Programs in California,”   Health Promotion Practice 4, No. 4 (2003): 430-438.
  54. Wei Y. Sun, Beatrice Sangweni, Gary Butts, Bernadette Nguyen, and Sara Ingster, “Assessment of an Outreach Program That Links Children Who Use New York City Immunization Clinics to Primary Care,” Health Marketing Quarterly 17, No. 1 (1999): 9-23.
  55. M. Michelle Manos, Wendy A. Leyden and Cynthia I. Resendez et al. “A Community-Based Collaboration to Assess and Improve Medical Insurance Status and Access to Health Care of Latino Children,” Public Health Reports 116 (November-December 2001): 575-584.
  56. Emily Feinberg, Katherine Swartz, Alan M. Zaslavsky, Jane Gardner, and Deborah K. Walker, “Language Proficiency and the Enrollment of Medicaid-Eligible Children in Publicly Funded Health Insurance Programs,” Maternal and Child Health Journal 6, No. 1 (2002): 5-18.
  57. Michael Perry.  New York’s Disaster Relief Medicaid. Insights and Implications for Covering Low-Income People.  (Washington, DC: The Kaiser Commission on Medicaid and the Uninsured, August 2002).
  58. Mireille Jacobson and Thomas C. Buchmueller, “Can Private Companies Contribute to Public Programs’ Outreach Efforts?  Evidence from California,” Health Affairs 26, No. 2 (2007): 538-548.
  59. Courtney E. Burke, Managing Medicaid Take-Up. The Complexity of Simplifying the Medicaid Application Process (Albany, NY: State University of New York, The Nelson A. Rockefeller Institute of Government, The American Federalism Group, January 2003).
  60. Cohen Ross and Hill, “Enrolling Eligible Children.” 
  61. Sheila Hoag and Judith Wooldridge, Improving Processes and Increasing Efficiency: The Case for States Participating in a Process Improvement Collaborative (Princeton, NJ: Robert Wood Johnson Foundation, September 2007).
  62. Karl Kronebusch and Brian Ebel, “Enrolling Children in Public Insurance: SCHIP, Medicaid and State Implementation,”  Journal of Health Politics, Policy and Law 29, No. 3 (2004): 451-489; Karl Kronebusch and Brian Ebel, “Simplifying Children’s Medicaid and SCHIP,” Health Affairs 23, No. 3 (2004): 233-246.
  63. Anne Dunkelberg, Simplified Eligibility for Children’s Medicaid in Texas: A Status Report at Nine Months (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, February 2003).
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  65. Stan Dorn and Genevieve M. Kenney, Automatically Enrolling Eligible Children and Families into Medicaid and SCHIP: Opportunities, Obstacles and Options for Federal Policymakers (New York: The Commonwealth Fund, June 2006).
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  68. Laura Summer and Cindy Mann, “Instability of Public Health Insurance Coverage For Children and Their Families.” 
  69. Laura Summer,  Accomplishments and Lessons from the State Solutions Initiative to Increase Enrollment in the Medicare Savings Programs  (New Brunswick, NJ: Rutgers Center for State Health Policy, May 2006).
  70. Cohen Ross and Hill, “Enrolling Eligible Children.”
  71. Hoag and Wooldridge, Improving Processes and Increasing Efficiency; Judith Wooldridge, Making Health Care a Reality for Low-Income Children and Families (Princeton, NJ: Mathematica Policy Research, Inc., February 2007).
  72. Cohen Ross and Hill, “Enrolling Eligible Children.”
  73. Pat Redmond, Medicaid and SCHIP Retention in Challenging Times: Strategies from Managed Care Organizations (Washington, DC: Center on Budget and Policy Priorities, September 2005).
  74. Laura Summer and Cindy Mann, “Instability of Public Health Insurance Coverage For Children and Their Families.” 
  75. Gerry Fairbrother, Heidi P. Emerson, and Lee Partridge, “How Stable Is Medicaid Coverage For Children?”  Health Affairs 26, No. 2 (2007): 520-528.
  76. Lisa McKean, Michael A. O’Connor and Amy Rynell, Applying Online: Technological Innovation for Income Support Programs in Four States.  (Center for Impact Research and the Heartland Alliance, January 2004); Kristen Wysen, Public Access to Online Enrollment for Medicaid and SCHIP (Oakland, CA: California HealthCare Foundation, May 2003).
  77. Margaret Fuller and Cindy Beauregard, “Choosing Health Care Online: A 7-Eleven Case Study,” Benefits Quarterly 19, No. 3 (2003): 23-27.
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  84. Jennifer R. Kincheloe and E.Richard Brown, The Effect of County“Outreach Environments” on Family Participation in Medi-Cal and Health Families (Los Angeles, CA: UCLA Center for Health Policy Research, July 2007).
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  96. Embry Howell and Dana Hughes, “A Tale of Two Counties:  Expanding Health Insurance Coverage for Children in California,” The Milbank Quarterly 84, No. 3 (2006): 521-554.
  97. Anna Aizer, “Public Health Insurance, Program Take-Up and Child Health,” Review of Economics and Statistics 89, No. 3 (2007): 400-415.
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  99. Castaneda, Clayson, and Rundall et al, “Promising Outreach Practices: Enrolling Low-Income Children.”
  100. Kincheloe and Brown, The Effect of County“Outreach Environments.”
  101. Mahajan, Stanley and Ross et al, “Evaluation of an Emergency Department-Based Enrollment Program for Uninsured Children.”
  102. Forti and Koerber, “An Outreach Intervention for Older Rural African Americans.”
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  104. Howell and Hughes, “A Tale of Two Counties.”
  105. Jenna Walls, Bridget Lavin, Kathy Gifford and Christopher Trenholm, Covering Kids and Families Evaluation.  Case Study of Arkansas: Exploring Medicaid and SCHIP Enrollment Trends and Their Links to Policy and Practice (Princeton, NJ: Mathematica Policy Research, Inc., July 2006).
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  107. Access to Benefits Coalition, Pathways to Success.  Meeting the Challenge of Enrolling Medicare Beneficiaries with Limited Incomes. 
  108. Howell and Hughes, “A Tale of Two Counties”; Michelle Niescierenko, Renee B. Cadzow and Chester H. Fox, “Insuring the Uninsured: A Student-Run Initiative to Improve Access to Care in an Urban Community,” Journal of the National Medical Association 98, No. 6 (2006): 906-911.
  109. Goulet, Rosenheck and Douglas, “Effectiveness of a Targeted Mailing Outreach Program on SSI Applications and Awards.”
  110. Sieben, Rosenberg and Bazile, “The Role of WIC Centers and Small Businesses in Enrolling Uninsured Children in Medicaid and Child Health Plus.”
  111. Dutton, Katz and Pennington, Using Community Groups and Student Volunteers to Enroll Uninsured Children in Medicaid and Child Health Plus.
  112. Wooldridge, Making Health Care a Reality for Low-Income Children.
  113. Laura Summer, Administrative Costs Associated with Enrollment and Renewal for the Medicare Savings Programs: A Case Study of Practices in Louisiana (New Brunswick, NJ: Rutgers Center for State Health Policy, February 2005).
  114. Minyard, Chollet and Felland et al, Lessons from Local Access Initiatives.
  115. Howell and Courtot, Covering Kids and Families Evaluation. Targeting Special Populations in the CKF Program.
  116. Janet B. Mitchell and Deborah S. Osber, “Using Medicaid/SCHIP To Insure Working Families: The Massachusetts Experience,” Health Care Financing Review 23, No. 3 (2002): 35-45.

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