Strategies for expanding health insurance coverage in vulnerable populations

Researchers in The Cochrane Collaboration conducted a review of the effect of strategies to increase the number of people from vulnerable populations that are enrolled into health insurance programmes. They searched for all relevant studies and found two studies. Their findings are summarised below.

What is a health insurance programme?

Governments in many countries offer healthcare services at low rates or free of charge to all their citizens, often paying for these services through taxes. However, in many developing countries and some developed countries this is not the case. In these countries, many people get their healthcare expenses covered through government health insurance programmes, which are often paid for through membership fees. But certain groups of people, such as children, the elderly, women, people with low incomes, people living in rural areas, racial and ethnic minorities, immigrants, and people with chronic diseases or disabilities, are less likely to be members of these programmes even though they are more likely to have health problems.

In some of these countries governments have tried to make sure that health insurance programmes cover these vulnerable groups. One way of doing this is to improve the design of the programme. For instance, governments can change the rules for who can join the programme or they can make it cheaper to join. But even if a programme is well-designed, people may still not join it. For instance, they may not know that they can become members or they may find the application process too difficult. To address these problems, for instance, governments can give people more information about the programme and who can join, or can make the application process easier.

What this research says

Both studies in this review took place in the USA and were aimed at uninsured children. In the first study, case managers contacted the families of uninsured Latin American children, gave them information about health insurance, helped them apply, and helped them appeal when a wrong decision was made. In the second study, insurance application forms were handed out to the families of children visiting hospital emergency departments. In both studies, these families were compared to families who were not given additional information or support. The studies showed the following:

People who are offered health insurance information and application support:

- are probably more likely to enrol their children into health insurance programmes (moderate quality evidence);

- are probably more likely to continue insuring their children (moderate quality evidence);

- may be quicker at getting insurance (low quality evidence);

- may be more satisfied with the process of enrolment (low quality evidence).

People who are given insurance application forms in the emergency departments of hospitals:

- may be more likely to enrol their children into health insurance programmes (low quality evidence).

No unwanted effects were reported in the studies. A possible unwanted effect might be that people could experience the information and support as annoying or unhelpful. However, in the one study that measured the parents’ satisfaction, people were more satisfied when given information and support.

A summary of this review for policy-makers is available here

Authors' conclusions: 

Community-based case managers who provide health insurance information, application support, and negotiate with the insurer probably increase enrolment of children in health insurance schemes. However, the transferability of this intervention to other populations or other settings is uncertain. Handing out insurance application materials in hospital emergency departments may help increase the enrolment of children in health insurance schemes. Further studies evaluating the effectiveness of different strategies for expanding health insurance coverage in vulnerable population are needed in different settings, with careful attention given to study design.

Read the full abstract...

Health insurance has the potential to improve access to health care and protect people from the financial risks of diseases. However, health insurance coverage is often low, particularly for people most in need of protection, including children and other vulnerable populations.


To assess the effectiveness of strategies for expanding health insurance coverage in vulnerable populations.

Search strategy: 

We searched Cochrane Central Register of Controlled Trials (CENTRAL), part of The Cochrane Library. (searched 2 November 2012), PubMed (searched 1 November 2012), EMBASE (searched 6 July 2012), Global Health (searched 6 July 2012), IBSS (searched 6 July 2012), WHO Library Database (WHOLIS) (searched 1 November 2012), IDEAS (searched 1 November 2012), ISI-Proceedings (searched 1 November 2012),OpenGrey (changed from OpenSIGLE) (searched 1 November 2012), African Index Medicus (searched 1 November 2012), BLDS (searched 1 November 2012), Econlit (searched 1 November 2012), ELDIS (searched 1 November 2012), ERIC (searched 1 November 2012), HERDIN NeON Database (searched 1 November 2012), IndMED (searched 1 November 2012), JSTOR (searched 1 November 2012), LILACS(searched 1 November 2012), NTIS (searched 1 November 2012), PAIS (searched 6 July 2012), Popline (searched 1 November 2012), ProQuest Dissertation &Theses Database (searched 1 November 2012), PsycINFO (searched 6 July 2012), SSRN (searched 1 November 2012), Thai Index Medicus (searched 1 November 2012), World Bank (searched 2 November 2012), WanFang (searched 3 November 2012), China National Knowledge Infrastructure (CHKD-CNKI) (searched 2 November 2012).

In addition, we searched the reference lists of included studies and carried out a citation search for the included studies via Web of Science to find other potentially relevant studies.

Selection criteria: 

Randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) studies and Interrupted time series (ITS) studies that evaluated the effects of strategies on increasing health insurance coverage for vulnerable populations. We defined strategies as measures to improve the enrolment of vulnerable populations into health insurance schemes. Two categories and six specified strategies were identified as the interventions.

Data collection and analysis: 

At least two review authors independently extracted data and assessed the risk of bias. We undertook a structured synthesis.

Main results: 

We included two studies, both from the United States. People offered health insurance information and application support by community-based case managers were probably more likely to enrol their children into health insurance programmes (risk ratio (RR) 1.68, 95% confidence interval (CI) 1.44 to 1.96, moderate quality evidence) and were probably more likely to continue insuring their children (RR 2.59, 95% CI 1.95 to 3.44, moderate quality evidence). Of all the children that were insured, those in the intervention group may have been insured quicker (47.3 fewer days, 95% CI 20.6 to 74.0 fewer days, low quality evidence) and parents may have been more satisfied on average (satisfaction score average difference 1.07, 95% CI 0.72 to 1.42, low quality evidence).

In the second study applications were handed out in emergency departments at hospitals, compared to not handing out applications, and may have had an effect on enrolment (RR 1.5, 95% CI 1.03 to 2.18, low quality evidence).