"To the best of our knowledge, this is the first study to demonstrate the elimination of a racial/ethnic disparity in health and healthcare," says Glenn Flores, MD, FAAP, associate professor of pediatrics, epidemiology and health policy at the Medical College and principal author of the study. "The intervention resulted in a dramatic increase in the number of Latino children being insured, surpassing even the percentage of insured Caucasian children," adds Dr. Flores. He is also director of the Center for the Advancement of Underserved Children, a joint program of the College and Children's Hospital.
Some 8.4 million children in the United States have no health insurance, despite the 1997 enactment of the State Children's Health Insurance Program (SCHIP) a federal initiative with $39 billion in funding. Latinos continue to be the most uninsured ethnic group, with 21 percent (2.9 million) uninsured. This rigorous, randomized, controlled trial of 275 children revealed that, compared with uninsured children in the Medicaid/SCHIP outreach and enrollment group, uninsured children assigned to community-based case managers were:
- Substantially more likely to obtain health insurance (96 percent vs. 57 percent of those without case managers), and had approximately eight times the adjusted odds of obtaining insurance.
- Significantly more likely to be continuously insured (78 percent vs. 30 percent of those without case managers).
- Obtained insurance faster (87.5 days vs. 134.8 days for those without case managers).
- Had parents who were substantially more satisfied with the process of obtaining insurance (80 percent vs. 29 percent).
Dr. Flores and his colleagues conducted the study in Boston from May 2002 to August 2004 with 275 uninsured Latino children and their parents. The children were assigned randomly to an intervention group with trained case managers or a control group that received traditional Medicaid and SCHIP outreach and enrollment.
Case managers provided information on program eligibility, helped families complete insurance applications, acted as a family liaison with Medicaid/SCHIP, and assisted in maintaining coverage. Traditional Medicaid /SCHIP outreach generally consists of direct mailings, flyers, radio advertisements, and toll-free telephone numbers but frequently with little or no assistance with the enrollment process itself.
Throughout the study, those families assigned a case manager were much more likely to be involved in the insurance plan. The case managers were bilingual Latina women (of Dominican, Puerto Rican, Mexican, or Colombian ethnicity) between 22 and 36 years of age. All had graduated from high school, some had obtained college degrees, and one had postgraduate training. None had any prior experience working as case managers insuring uninsured children, but all received specific training for the study.
"By eliminating the racial/ethnic element - having people from the same culture act as interpreters and advocates - we found remarkable success in the program," Dr. Flores says. He believes the results show that case management could not only effectively reduce the number of uninsured children in a community, but also might serve as a means of enhancing employment opportunities and revitalizing impoverished Latino neighborhoods.
"The case managers could be trained individuals from the community who serve their own community, drawn from welfare-to-work and other local and state employment programs. Part of the case manager earnings, in turn, might be spent at local businesses, resulting in a triple effect of reducing the number of uninsured children, increasing parental employment, and stimulating the local economy," Dr. Flores says.
Co-authors of the study include Ramesh C. Sachdeva, M.D. Ph.D., MBA, associate professor of pediatrics at the Medical College; and the following faculty from the Boston University Schools of Medicine and Public Health: Milagros Abreu, M.D., Christine E. Chaisson, MPH, Alan Meyers, M.D., MPH, Harriet Fernandez, Patricia Francisco, Beatriz Diaz, Ana Milena Diaz, and Iris Santos-Guerrero.
Editor's Note: Dr. Flores is scheduled to provide a Congressional briefing on December 6 at 10:00 a.m. (ET) concerning these issues