The health and healthcare impact of providing insurance coverage to uninsured children: A prospective observational study.

BACKGROUND: Of the 4.8 million uninsured children in America, 62-72% are eligible for but not enrolled in Medicaid or CHIP. Not enough is known, however, about the impact of health insurance on outcomes and costs for previously uninsured children, which has never been examined prospectively. METHODS: This prospective observational study of uninsured Medicaid/CHIP-eligible minority children compared children obtaining coverage vs. those remaining uninsured. Subjects were recruited at 97 community sites, and 11 outcomes monitored monthly for 1 year. RESULTS: In this sample of 237 children, those obtaining coverage were significantly (P < .05) less likely than the uninsured to have suboptimal health (27% vs. 46%); no PCP (7% vs. 40%); experienced never/sometimes getting immediate care from the PCP (7% vs. 40%); no usual source of preventive (1% vs. 20%) or sick (3% vs. 12%) care; and unmet medical (13% vs. 48%), preventive (6% vs. 50%), and dental (18% vs. 62%) care needs. The uninsured had higher out-of-pocket doctor-visit costs (mean = $70 vs. $29), and proportions of parents not recommending the child's healthcare provider to friends (24% vs. 8%) and reporting the child's health caused family financial problems (29% vs. 5%), and lower well-child-care-visit quality ratings. In bivariate analyses, older age, birth outside of the US, and lacking health insurance for >6 months at baseline were associated with remaining uninsured for the entire year. In multivariable analysis, children who had been uninsured for >6 months at baseline (odds ratio [OR], 3.8; 95% confidence interval [CI], 1.4-10.3) and African-American children (OR, 2.8; 95% CI, 1.1-7.3) had significantly higher odds of remaining uninsured for the entire year. Insurance saved $2886/insured child/year, with mean healthcare costs = $5155/uninsured vs. $2269/insured child (P = .04). CONCLUSIONS: Providing health insurance to Medicaid/CHIP-eligible uninsured children improves health, healthcare access and quality, and parental satisfaction; reduces unmet needs and out-of-pocket costs; and saves $2886/insured child/year. African-American children and those who have been uninsured for >6 months are at greatest risk for remaining uninsured. Extrapolation of the savings realized by insuring uninsured, Medicaid/CHIP-eligible children suggests that America potentially could save $8.7-$10.1 billion annually by providing health insurance to all Medicaid/CHIP-eligible uninsured children.

A cross-sectional study of parental awareness of and reasons for lack of health insurance among minority children, and the impact on health, access to care, and unmet needs.

BACKGROUND: Minority children have the highest US uninsurance rates; Latino and African-American children account for 53 % of uninsured American children, despite comprising only 48 % of the total US child population. The study aim was to examine parental awareness of and the reasons for lacking health insurance in Medicaid/CHIP-eligible minority children, and the impact of the children's uninsurance on health, access to care, unmet needs, and family financial burden. METHODS: For this cross-sectional study, a consecutive series of uninsured, Medicaid/CHIP-eligible Latino and African-American children was recruited at 97 urban Texas community sites, including supermarkets, health fairs, and schools. Measures/outcomes were assessed using validated instruments, and included sociodemographic characteristics, uninsurance duration, reasons for the child being uninsured, health status, special healthcare needs, access to medical and dental care, unmet needs, use of health services, quality of care, satisfaction with care, out-of-pocket costs of care, and financial burden. RESULTS: The mean time uninsured for the 267 participants was 14 months; 5 % had never been insured. The most common reason for insurance loss was expired and never reapplied (30 %), and for never being insured, high insurance costs. Only 49 % of parents were aware that their uninsured child was Medicaid/CHIP eligible. Thirty-eight percent of children had suboptimal health, and 2/3 had special healthcare needs, but 64 % have no primary-care provider; 83 % of parents worry about their child's health more than others. Unmet healthcare needs include: healthcare, 73 %; mental healthcare, 70 %; mobility aids/devices, 67 %; dental, 61 %; specialty care, 57 %; and vision, 46 %. Due to the child's health, 35 % of parents had financial problems, 23 % cut work hours, and 10 % ceased work. Higher proportions of Latinos lack primary-care providers, and higher proportions of African-Americans experience family financial burden. CONCLUSIONS: Half of parents of uninsured minority children are unaware that their children are Medicaid/CHIP-eligible. These uninsured children have suboptimal health, impaired access to care, and major unmet needs. The child's health causes considerable family financial burden, and one in 10 parents ceased work. The study findings indicate urgent needs for better parental education about Medicaid/CHIP, and for improved Medicaid/CHIP outreach and enrollment.

Parent Mentoring Program Increases Coverage Rates For Uninsured Latino Children.

Latinos have the highest US childhood uninsurance rate of any race/ethnicity, but little is known about effective ways to eliminate this disparity. We evaluated the effects of parent mentors-Latino parents with children covered by Medicaid or the Children's Health Insurance Program-on insuring Latino children in a randomized, controlled, community-based trial of 155 uninsured children conducted in the period 2011-15. Parent mentors were trained to assist families in getting insurance coverage, accessing health care, and addressing social determinants of health. We found that parent mentors were more effective than traditional methods in insuring children (95 percent versus 69 percent), achieving faster coverage and greater parental satisfaction, reducing unmet health care needs, providing children with primary care providers, and improving the quality of well-child and subspecialty care. Children in the parent-mentor group had higher quality of overall and specialty care, lower out-of-pocket spending, and higher rates of coverage two years after the end of the intervention (100 percent versus 70 percent). Parent mentors are highly effective in insuring uninsured Latino children and eliminating disparities.

A successful approach to minimizing attrition in racial/ethnic minority, low-income populations.

BACKGROUND: Recruiting and retaining minority participants in clinical trials continue to be major challenges. Although multiple studies document lower minority trial enrollment, much less is known about effective minority retention strategies. Our objectives were to evaluate an innovative approach to high RCT retention of minority children, and identify child/caregiver characteristics predicting attrition. METHODS: The Kids' HELP trial examined the effects of Parent Mentors on insuring uninsured minority children. We tested a retention strategic framework consisting of: 1) optimizing cultural/linguistic competency; 2) staff training on participant relationships and trust; 3) comprehensive participant contact information; 4) an electronic tracking database; 5) reminders for upcoming outcomes-assessment appointments; 6) frequent, sustained contact attempts for non-respondents; 7) financial incentives; 8) individualized rapid-cycle quality-improvement approaches to non-respondents; 9) reinforcing study importance; and 10) home assessment visits. We compared attrition in Kids' HELP vs. two previous RCTs in similar populations, and conducted bivariate and multivariable analyses of factors associated with Kids' HELP attrition. RESULTS: Attrition in Kids' HELP was lower than in two similar RCTs, at 10.9% vs. 37% and 40% (P <0.001). After multivariable adjustment, missing the first outcomes follow-up assessment was the only factor significantly associated with attrition (relative risk=1.5; 95% confidence interval, 1.1-2.0). CONCLUSIONS: A retention strategic framework was successful in minimizing attrition in minority, low-income children. Participants missing first assessment appointments were at highest risk of subsequent attrition. These findings suggest that deploying this framework may help RCT retention of low-income minority children, particularly those at the highest risk of subsequent attrition.

An Innovative Methodological Approach to Building Successful Community Partnerships for Improving Insurance Coverage, Health, and Health Care in High-Risk Communities.

BACKGROUND: More than 48% of U.S. children are racial/ethnic minorities, 21% are poor, and 6% are uninsured. It is unclear, however, what methods are most effective for identifying and engaging community partners in study enrollment of these children in high-risk communities. OBJECTIVE: Evaluate a new methodological approach to the screening, identification, and intervention study enrollment of uninsured minority children. METHODS: We developed, implemented, and evaluated a methodological approach consisting of four components: (1) identify communities with the highest proportions of low-income minority families with uninsured children, (2) hire minority research staff responsible for community engagement and data collection, (3) implement and evaluate a parent mentor (PM) intervention built on community partnerships and which creates jobs, and (4) successfully execute the research by engaging appropriate community partners. RESULTS: PMs were successfully recruited (n = 15) and trained (test scores significantly improved). Large numbers (n = 97) of appropriate, diverse community partners were engaged.The most productive community partners for recruitment were schools and childcare establishments, community-based organizations, discount and niche stores, supermarkets, and churches. Community partnerships resulted in 49,631 candidate participants screened and 329 enrolled in the study. The intervention was highly successful, with PMs significantly more effective and faster than traditional outreach/enrollment in insuring uninsured minority children, sustaining coverage, improving care access, reducing out-of-pocket costs, and achieving parental satisfaction and care quality, while saving $6,045 per child insured per year. CONCLUSIONS: This innovative, community-based methodology is highly effective, and could prove useful for community-based interventions targeting a variety of childhood and adult health, health-care, and equity issues.

Parent Mentors and Insuring Uninsured Children: A Randomized Controlled Trial.

BACKGROUND: Six million US children are uninsured, despite two-thirds being eligible for Medicaid/Children's Health Insurance Program (CHIP), and minority children are at especially high risk. The most effective way to insure uninsured children, however, is unclear. METHODS: We conducted a randomized trial of the effects of parent mentors (PMs) on insuring uninsured minority children. PMs 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. The primary outcome was obtaining insurance 1 year post-enrollment. RESULTS: We enrolled 237 participants (114 controls; 123 in PM group). PMs were more effective (P< .05 for all comparisons) than traditional methods in insuring children (95% vs 68%), and achieving faster coverage (median = 62 vs 140 days), high parental satisfaction (84% vs 62%), and coverage renewal (85% vs 60%). PM children were less likely to have no primary care provider (15% vs 39%), problems getting specialty care (11% vs 46%), unmet preventive (4% vs 22%) or dental (18% vs 31%) care needs, dissatisfaction with doctors (6% vs 16%), and needed additional income for medical expenses (6% vs 13%). Two years post-PM cessation, more PM children were insured (100% vs 76%). PMs cost $53.05 per child per month, but saved $6045.22 per child insured per year. CONCLUSIONS: 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.

Design, methods, and baseline characteristics of the Kids' Health Insurance by Educating Lots of Parents (Kids' HELP) trial: a randomized, controlled trial of the effectiveness of parent mentors in insuring uninsured minority children.

BACKGROUND & OBJECTIVES: Six million US children have no health insurance, and substantial racial/ethnic disparities exist. The design, methods, and baseline characteristics are described for Kids' Health Insurance by Educating Lots of Parents (Kids' HELP), the first randomized, clinical trial of the effectiveness of Parent Mentors (PMs) in insuring uninsured minority children. METHODS & RESEARCH DESIGN: Latino and African-American children eligible for but not enrolled in Medicaid/CHIP were randomized to PMs, or a control group receiving traditional Medicaid/CHIP outreach. PMs are experienced parents with ≥1 Medicaid/CHIP-covered children. PMs received two days of training, and provide intervention families with information on Medicaid/CHIP eligibility, assistance with application submission, and help maintaining coverage. Primary outcomes include obtaining health insurance, time interval to obtain coverage, and parental satisfaction. A blinded assessor contacts subjects monthly for one year to monitor outcomes. RESULTS: Of 49,361 candidates screened, 329 fulfilled eligibility criteria and were randomized. The mean age is seven years for children and 32 years for caregivers; 2/3 are Latino, 1/3 are African-American, and the mean annual family income is $21,857. Half of caregivers were unaware that their uninsured child is Medicaid/CHIP eligible, and 95% of uninsured children had prior insurance. Fifteen PMs completed two-day training sessions. All PMs are female and minority, 60% are unemployed, and the mean annual family income is $20,913. Post-PM-training, overall knowledge/skills test scores significantly increased, and 100% reported being very satisfied/satisfied with the training. CONCLUSIONS: Kids' HELP successfully reached target populations, met participant enrollment goals, and recruited and trained PMs.

A successful program for training parent mentors to provide assistance with obtaining health insurance for uninsured children.

OBJECTIVE: Seven million US children lack health insurance. Community health workers are effective in insuring uninsured children, and parent mentors (PMs) in improving asthmatic children's outcomes. It is unknown, however, whether a training program can result in PMs acquiring knowledge/skills to insure uninsured children. The study aim was to determine whether a PM training program results in improved knowledge/skills regarding insuring uninsured minority children. METHODS: Minority parents in a primary-care clinic who already had Medicaid/Children's Health Insurance Program (CHIP)-covered children were selected as PMs, attending a 2-day training session addressing 9 topics. A 33-item pretraining test assessed knowledge/skills regarding Medicaid/CHIP, the application process, and medical homes. A 46-item posttest contained the same 33 pretest items (ordered differently) and 13 Likert-scale questions on training satisfaction. RESULTS: All 15 PMs were female and nonwhite, 60% were unemployed, and the mean annual income was $20,913. After training, overall test scores (0-100 scale) significantly increased, from a mean of 62 (range 39-82) to 88 (range 67-100) (P < .01), and the number of wrong answers decreased (mean reduction 8; P < .01). Significant improvements occurred in 6 of 9 topics, and 100% of PMs reported being very satisfied (86%) or satisfied (14%) with the training. Preliminary data indicate PMs are significantly more effective than traditional Medicaid/CHIP outreach/enrollment in insuring uninsured minority children. CONCLUSIONS: A PM training program resulted in significant improvements in knowledge and skills regarding outreach to and enrollment of uninsured, Medicaid/CHIP-eligible children, with high levels of satisfaction with the training. This PM training program might be a useful model for training Patient Protection and Affordable Care Act navigators.

Rationale for use of an exercise end point and design for the ADVANCE (A Dose evaluation of a Vasopressin ANtagonist in CHF patients undergoing Exercise) trial.

BACKGROUND: Exercise intolerance is a primary characteristic of chronic congestive heart failure. Exercise testing is therefore widely used to evaluate the degree of functional impairment, prognosis of underlying cardiac disease, and response to treatment. Historically, studies that used exercise tolerance as an end point to evaluate the efficacy of pharmacologic interventions have been confounded by methodologic differences involving protocols, exercise end points, absence or misuse of gas exchange data, and study design. METHODS: The purpose of this study was to outline the methodology and rationale of a unique cardiopulmonary exercise trial. The design was based on prior experience from evaluation of ACE inhibitors and other interventions. The ADVANCE (A Dose evaluation of a Vasopressin ANtagonist in CHF patients undergoing Exercise) trial is a multicenter, double-blind, placebo-controlled, randomized trial investigating the effects of a vasopressin antagonist, conivaptan, on functional capacity in patients with heart failure. RESULTS: The primary end point is change in the exercise time to reach 70% of peak oxygen consumption during an incremental exercise test. Secondary end points include changes in peak oxygen consumption and other exercise parameters as well as quality-of-life indicators. The study incorporates several unique features to lessen potential methodological errors of exercise testing in heart failure, including use of a core laboratory to evaluate exercise tests, a computer program to determine the exercise end points, and validation of each site before patient enrollment. CONCLUSIONS: The results of this study will have value not only for the further use of vasopressin antagonists for heart failure therapy but also for the use of exercise testing and gas exchange determination for the evaluation of new drug therapies.

Endothelial stimulation by small lymphocytic lymphoma correlates with secreted levels of basic fibroblastic growth factor.

Lymph nodes (LN) involved with small lympho- cytic lymphoma (SLL) reportedly contain increased numbers of microvessels that may constitute a therapeutic target in this disease. We investigated the secretion of the angiogenic growth factor, basic fibroblastic growth factor (bFGF), from primary tissue cultures of 15 LN with SLL and 10 reactive LN. bFGF was detected from the resulting conditioned media (CM) in 13/15 SLL samples (mean 92 +/- 30, range 5-420 pg/ml) but was undetectable in CM from all reactive lymph nodes. CM was also used in a 72-h human umbilical vein endothelial cell (HUVEC) proliferation assay. HUVEC proliferation increased in the presence of SLL CM (70 +/- 17%, range -4-194%), proportional to secreted levels of bFGF (R2 = 0.95), and was reversed by depleting bFGF from CM. Previous SLL studies have examined either patient serum samples or paraffin-embedded lymph node tissue sections. This is the first study to examine the secretion of an angiogenic growth factor from primary cultures of lymph node cells. Our results indicate that bFGF is probably the primary mediator responsible for increased angiogenesis in involved nodes. These findings may be pertinent to future investigation into the mechanisms of increased angiogenesis in SLL.