Summary of Project Results

Barriers to Facilitated Enrollment Among Uninsured African Americans

Summary of Project Results

Specific Aims:

To conduct semi-structured in—depth interviews of a consecutive sample of 200 uninsured new patients presenting to a free medical clinic to assess awareness and attitude of government supported heath coverage options and the facilitated enrollment programs that are available to assist them.

The researcher was able to collaborate with the student-established Lighthouse Insurance Initiative (LII) in order to accomplish the aims of this project. The LII was established by medical student volunteers in 2003 in order to assist patients presenting at the Lighthouse with insurance acquisition. Volunteers with the LII asked every patient whether they were insured and, if not, whether they were interested in finding out if they were eligible. The volunteers tracked the progress of each application completed. Rather than complicate matters further, a separate interview was not conducted with 200 uninsured new patients, but rather the data from the LII and insights from volunteers was used to satisfy the aims of this project. Data from 579 patient screenings was analyzed. Out of a total of 319 uninsured new patients, 224 were screened for their insurance eligibility. The screening questions used by the LII to determine eligibility before starting the enrollment process reflect income criteria set by each program. Factors evaluated by screening include employment status, monthly income, composition of household and who in the household desires insurance.Nearly everyone who was eligible for insurance (59 applicants) was unaware that they were eligible at the initiation of the application. Few were able to navigate the system on their own without the help of the volunteers working as “financial case managers” for them.

One hundred eighteen (118) uninsured patients were found to be ineligible for Medicaid, Family Health Plus, or Child Health Plus. The reasons for ineligibility are detailed in Figure 2. Twenty patients (9%) indicated they were not interested in learning about their insurance options. This may have been due to time constraints or perhaps it was an issue of pride. Further exploration of this subset of people is necessary. It is promising, however, that only 9% expressed disinterest in learning more about available insurance.

To utilize the identified knowledge of and attitude toward facilitated enrollment among uninsured African Americans to determine barriers that exist to the acceptance and social marketing of facilitated enrollment in urban underserved communities.

As stated previously, nearly everyone who was eligible for insurance was unaware that they were eligible at the initiation of the application. This suggests that perhaps social marketing is not reaching this population or that it is using an ineffective medium. Additionally, barriers can be identified by looking at the number of people that were lost-to-follow-up in this insurance initiative. Out of 57 applications, 25 (44%) were lost to follow-up. This is unacceptably high. By looking at the reasons that patients were lost to follow-up we can devise some possible solutions to remedy it in the future.

The primary reason patients were lost to follow-up is that three months passed without word or further action by the applicant. The second most common reason was a disconnected phone line. One person expressed that he/she was no longer interested.

Not much can be done about patients with disconnected phone lines. Those that were lost after three months of phone calls may benefit from more frequent nights in which the FE is available at the clinic (rather than once/month) as well as additional locations/times that those patients may be able to meet with a FE. People are often too busy with work, school, etc to visit a clinic on one specified day of the month; if there were additional dates/times/locations, those people may be able to follow-up with their enrollment. Further research is needed with people in this population in order to assess if this is accurate.

To recommend research-based policy and program changes to the facilitated enrollment initiatives designed to assist the urban uninsured.

As indicated by the LII medical student volunteers, few of the insurance applicants were able to navigate the system on their own without the help of the volunteers working as “financial case managers” for them. Having volunteers assist with the application process prior to the applicants meeting with the facilitated enroller seems to enable many eligible people to apply for insurance who had not done so up until this point. This model could be repeated in other locations where facilitated enrollers are present in order to guide uninsured people through the whole process. Using health services student volunteers serves two functions: 1) enabling successful facilitated enrollment without adding additional person-costs and 2) providing a venue for health services students to learn about health and insurance issues facing urban underserved people.

An alternate possibility is to recruit people from the community to help guide people through the insurance process. There may be even greater acceptance of the initiative if the volunteers are members of the same community.

Index of Tables and Figures:

Table 1: Characteristics of Screened Clinic Patients (Age, sex, and race/ethnicity of uninsured new clinic patients who underwent screening for insurance eligibility)

Figure 1: Insurance Applicants Oct 2003-Oct 2004(Tree diagram of patients presenting at clinic who were asked about insurance status, were subsequently screened for eligibility, filled out applications, and acquired insurance)

Figure 2: Reasons for Insurance Ineligibility(pie chart of reasons that patients were found to be ineligible for Medicaid, Child Health Plus, or Family Health Plus)

Figure 3: Results from Insurance Application(bar graph illustrating the results of the 57 LII-assisted insurance applications)

Figure 4: Reasons Lost to Follow-up(bar graph illustrating the reasons that 25 applications were lost to follow-up)

Table 1: Characteristics of Screened Clinic Patients
Race/Ethnicity / Age / Male / Female / TOTAL
Caucasian / 0-9 / 0 / 1 / 1
20-29 / 4 / 2 / 6
30-39 / 2 / 1 / 3
40-49 / 2 / 3 / 5
50-59 / 1 / 0 / 1
60-69 / 1 / 1 / 2
Total / 10 / 8 / 18
African-American / 0-9 / 7 / 13 / 20
10-19 / 27 / 35 / 62
20-29 / 7 / 9 / 16
30-39 / 13 / 10 / 23
40-49 / 25 / 12 / 37
550-59 / 8 / 8 / 16
60-69 / 6 / 8 / 14
70-79 / 0 / 1 / 1
Total / 93 / 96 / 189
Hispanic/Latino / 0-9 / 0 / 1 / 1
20-29 / 0 / 1 / 1
Total / 0 / 2 / 2
Mixed ethnicity / 10-19 / 0 / 1 / 1
20-29 / 1 / 0 / 1
40-49 / 1 / 0 / 1
Total / 2 / 1 / 3
TOTAL / 105 / 107 / 212

Figure 1: Insurance Applicants Oct 2003-Oct 2004