Program Eligibility Research Articles

Association between early income variation around poverty thresholds, income trajectories, and birth, child, and family characteristics

Poverty is experienced by about 15% of children under the age of six in the United States at any given time and over 40% of children at least once prior to kindergarten entry. Given that many families experience dips in and out of poverty prior to school entry, increasing research focuses on early household economic conditions and family income instability among such families. Using Early Childhood Longitudinal Study-Birth Cohort data (2001–2007) sampling children in poor and moderate income families and two relevant theoretical frameworks, the present study investigated (a) the extent to which income varies around the official poverty threshold (as well as other relevant thresholds used to determine social safety net program eligibility) in a subsample of low-to-moderate income families, and (b) the early, time-variant factors associated with membership in specific birth to kindergarten income trajectories as well as fluctuations around well-used income thresholds in a subsample of low-to-moderate income families. Sixty-seven percent of children in the study were classified in the stable low income trajectory, and findings suggest the majority of these children oscillated above and below 100% Federal Poverty Level (FPL) at various times throughout early childhood (55%). Results also suggest birth, child, and family characteristics such as changes in maternal depression, maternal work status, and household composition differentiate income trajectory class membership and are associated with income fluctuation around 100% FPL and 130% FPL. Findings are discussed in the context of current dialogue about the nature of family poverty over time, and the limitations of social policy responses that attend to family needs at one point-in-time without consideration of trajectories and the consequences of cyclical poverty for children and their families.

State Laws on Substance Use Treatment for Incarcerated Pregnant and Postpartum People.

Incarcerated perinatal populations report high rates of substance use in the United States (US). Despite this, substance use disorder (SUD) treatment is not routinely available in carceral settings and state policies related to the provision of substance use screening and treatment are unknown. We conducted a systematic search in WestLaw through the end of the 2020 legislative session combining the terms "pregnant" and "postpartum" with terms for incarceration and related terms. The search returned 453 statutes from 43 states. A deductive codebook of various maternal health topics was developed. Legislative texts related to SUD screening and treatment were extracted for textual analysis. Of the 43 states identified as having at least 1 state statute pertaining to pregnant or postpartum incarcerated people, 7 states had statutes relevant to SUD screening and treatment. Statutes related to substance use screening, education, treatment and diversion programs, program eligibility, aftercare and release planning, and funding appropriations. The majority of states across the U.S. lack legislation that address SUD screening and treatment among incarcerated perinatal populations. Given the known limited access to SUD treatment for perinatal populations in custody, increasing legislative statutes could increase access to essential care.

Diabetes and Hypertension Prevention and Control in Community Health Centers: Impact of the Affordable Care Act.

Access to care significantly improved following the implementation of the Patient Protection and Affordable Care Act. Since its implementation, the number of uninsured Americans has significantly decreased. Medicaid expansion played an important role in community health centers, who serve historically marginalized populations, leading to increased clinic revenue, and improved access to care. As the continuous Medicaid enrollment provision established during the pandemic ended, and states have to make decisions about their program eligibility, exploring the impact of Medicaid expansion on the detection, and management of hypertension and diabetes could inform these decisions. We summarized the effect of Medicaid expansion on community health centers and their patients specific to hypertension and diabetes from existing literature. These studies suggest the beneficial impact of the Affordable Care Act and acquiring insurance on diabetes and hypertension disease detection, treatment, and control for patients receiving care in community health centers. Overall, these studies suggest the clear importance of health insurance coverage, and notably insurance stability, on diabetes and hypertension control.

Examining SNAP and TANF caseload trends, responsiveness, and policies during the COVID‐19 pandemic

AbstractTemporary Assistance for Needy Families (TANF) and Supplemental Nutrition Assistance Program (SNAP) cases increased by 3.3 million between March and June 2020, their largest quarterly increase ever. During the pandemic, many states adopted a wide set of policies and procedures to facilitate program enrollment, retention, and eligibility. I track these policies and create a pandemic policy index measuring state generosity. States that adopted more generous policies experienced larger TANF and SNAP caseload growth, especially eligibility policies such as exempting TANF work requirements or SNAP P‐EBT availability. Analyzing the caseload relationship to labor markets, caseloads were less responsive to unemployment rate changes during the pandemic relative to the pre‐pandemic period.

Abstract 13737: An Electronic Health Record-Based Algorithm to Optimize Secondary Prevention Using Lipoprotein(a), Apolipoprotein B, Cholesterol, and Myocardial Infarction Diagnosis: ABCDs Prevention Program

Background : According to the 2022 American Heart Association Heart Disease and Stroke Statistics, coronary heart disease remains the leading cause of death attributable to cardiovascular disease (CVD). In 2016 only ~1 in 4 Medicare beneficiaries who were eligible for cardiac rehab (CR) participated. We explored the use of cardiovascular biomarkers and electronic health records (EHRs) to facilitate the early identification of patients at high risk for CVD. Methods : The EHR algorithm uses a combination of cardiovascular biomarkers and ICD diagnosis codes to automatically identify and refer patients to select secondary prevention programs: (1) traditional CR, (2) lipid clinic, (3) virtual CR (Corrie Health Program). In order to determine program eligibility our model uses criteria of lipoprotein(a) >70 nmol/L, apolipoprotein B >90 mg/dL, low-density lipoprotein cholesterol >150 mg/dL, triglycerides >200 mg/dL , and/or a diagnosis of ST-elevation myocardial infarction (MI) or non-ST-elevation MI as depicted in Figure 1. Lipid biomarker cutoffs were defined to maximize sensitivity for familial hyperlipidemia. Results : In a test environment 90% of patients deemed eligible by the algorithm received appropriate referrals to traditional, virtual (Corrie) CR and lipid clinics. The algorithm is currently being used in both inpatient units and outpatient clinics at Johns Hopkins Hospital and Johns Hopkins Bayview. Sixty-six percent of the orders placed increased referrals to CR and lipid clinic and 33% of the orders placed increased referrals to virtual cardiac rehab. Conclusions : Building an EHR-based algorithm to individualize CVD prevention using cardiovascular biomarkers and diagnoses may increase early identification and intervention on high-risk patients.

Whom Do Incentive Program Physicians Serve? New Measures for Assessing Program Reach.

One approach to ameliorating health workforce maldistribution is incentivizing health professionals, including physicians, to locate in underserved areas. However, eligibility for programs typically relies on large geographic areas whereas it is subpopulations within underserved areas who are typically at risk. New measures introduced in this article capture data on the patients actually served by incentive program physicians. A pilot study of one state's J-1 Visa Waiver and loan repayment programs validated the new measures of medical need, low income, rural location, and population-to-provider ratios of provider location, providing a nuanced picture of the groups actually served by incentive program physicians.

Predictors of Mortality in Home Health Care Service: Data from Saudi Arabia.

ObjectiveThis study aimed to 1) report the prevalence of chronic conditions among Saudi people receiving long-term home health care (HHC) services, 2) identify the predictors of mortality among individuals receiving long-term HHC services, and 3) study the association between frailty and poor health outcomes among HHC users.DesignRetrospective cross-sectional descriptive study.Setting and ParticipantsA total of 555 participants were recruited from HHC services at King Saud University Medical City (KSUMC), Riyadh, Saudi Arabia. We collected the data from electronic health records (EHR), patient charts, and caregiver interviews for 555 participants included in HHC program from the year 2019 to 2022.MethodsOnly individuals fulfilling the HHC program’s eligibility criteria were included to the study. A total of 555 participants were included in the analysis. We assessed the functional performance by the Katz activity of daily living and Bristol Activity of Daily Living Scale (BADLS). A trained health care provider assessed frailty using the Clinical Frailty Scale (CFS). We calculated the means and frequency to describe the prevalence of chronic conditions and variables of interest. A Chi-square test or independent-samples t-test was run to determine if there were differences between the alive and deceased individuals. A binary logistic regression model was performed to predict mortality of HHC service recipients.ResultsThe mean age for deceased individuals in HHC was 78.3 years. Over twenty percent of individuals receiving HHC services were readmitted to the hospital. We found that the strongest predictors for mortality were pressure ulcers with an odds ratio of 3.75 and p-value of <0.0001, and the Clinical Frailty Scale, which had an odds ratio of 1.69 and p-value of 0.002, using multivariate regression analysis.Conclusions and ImplicationsIn conclusion, our study found that pressure ulcers and frailty are the strongest predictors of mortality for individuals receiving home health care services.

The Impact of Financial Assistance Programs on Health Care Utilization: Evidence from Kaiser Permanente.

Most hospitals have financial assistance programs for low-income patients. We use administrative data from Kaiser Permanente to study the effects of financial assistance on healthcare utilization. Using a regression discontinuity design based on an income threshold for program eligibility, we find that financial assistance increases the likelihood of an inpatient, ambulatory and emergency department encounter by 3.6 pp (59%), 13.4 pp (20%), and 6.7 pp (53%), respectively, though effects dissipate three quarters after program receipt. Financial assistance also increases the detection and management of treatment-sensitive conditions (e.g., drugs treating diabetes), suggesting financial assistance may increase receipt of high-value care.

Community Stakeholders' Perceptions on Barriers and Facilitators to Food Security of Families with Children under Three Years before and during COVID-19.

Children living in food-insecure households have poorer overall health than children in food-secure households. While U.S. nutrition assistance programs provide resources, these cannot consistently offer age-appropriate nutritional foods for young children. This study aimed to determine community stakeholders’ perceptions of the barriers and facilitators to obtaining adequate, high-quality, and age-appropriate foods for children ages 0–3 in Florida before and during COVID-19. Community stakeholders (n = 32) participated in a 60 min interview via Zoom using a semi-structured script based on the PRECEDE component of the PRECEDE–PROCEED model. Interviews were transcribed verbatim and coded by two researchers using a thematic analysis approach. Stakeholders’ perceptions revealed a lack of awareness surrounding eligibility for assistance programs, a lack of knowledge regarding how to obtain resources and services, and stigma associated with receiving benefits. These remained significant barriers to obtaining healthful foods for households with young children before and during COVID-19. Nonetheless, barriers were exacerbated during the pandemic. Unemployment rates rose, intensifying these households’ financial hardships and food insecurity levels. Likewise, stakeholders suggested the need for families to become more aware of federal assistance eligibility requirements and available opportunities via social media and referrals. Identifying risk factors associated with food insecurity can inform future interventions to safeguard young children’s health and well-being.

Understanding Concordance in Health Behaviours among Couples: Evidence from the Bowel Cancer Screening Programme in England

Health behaviours depend upon preferences and individuals’ assessments of the long-term costs and benefits to themselves and others. We investigate family spillovers by examining couple concordance in uptake of bowel cancer screening using the English Longitudinal Study of Ageing. We exploit the sharp age cut-off for screening programme eligibility at age 60 and use polynomial regression to study how initial screening participation depends upon partner's uptake. We find that individuals with screened older partners are 42 percentage points more likely to screen than individuals with non-screened older partners, whose probability of screening is similar to comparable singles. Additionally, eligible but non-screened individuals update their screening behaviour if their younger partners participate in screening once they became eligible. We find heterogeneity in this concordance that is consistent with learning among partners being the most likely mechanism driving couple concordance. The findings have important implications for the optimal design of population-wide screening campaigns.

Facility-based simulation as a programmatic tool for implementing a statewide contraceptive initiative

BackgroundAssessing implementation fidelity is highly recommended, but successful approaches can be challenging. Family Planning Elevated (FPE) is a statewide contraceptive initiative which partnered with 28 health clinics across Utah. To assess implementation fidelity, we developed in-situ high-fidelity simulation training to both determine clinic adherence to FPE and offer education to implementing teams. This study aimed to develop, pilot, and assess the use of simulation as a tool for measuring implementation fidelity.MethodsWe developed two simulation scenarios to determine implementation fidelity: one scenario wherein a client is seeking a new method of contraception and another in which the same client has returned to discontinue the method. Both simulations contained multiple aspects of program implementation (e.g., determining program eligibility). We then offered simulations to all FPE partner organizations. To assess simulation training as a tool for determining implementation fidelity, we developed strategies aligned with each aspect of an adapted RE-AIM framework, including pre-post surveys, acceptability and self-efficacy testing, a checklist for programmatic adherence, field notes, action planning and analysis of monitoring data.ResultsFifteen clinical sites and 71 team members participated in the in-situ simulations. Assessment of the checklist showed that 90% of the clinics successfully demonstrated key program components, including person-centered counseling techniques such as sitting at the patient’s level (95.8%); asking open-ended questions (100%); and explaining how to use the contraceptive method selected (91.7%). More than half of clinics fell short in programmatic areas including: confirmation that the FPE program covered same-day intrauterine device insertion (54.2%), and education on health risks associated with the selected contraceptive method (58.3%). After simulation, participants reported improved knowledge of how FPE works (p = < 0.001), increased ability to identify FPE-eligible clients (p = 0.02) and heightened self-efficacy in helping clients select a method (p = 0.03). Participants were satisfied with the simulations, with most (84.1%) reporting that the simulation exceeded their expectations.ConclusionsHighly-realistic in-situ family planning simulations are acceptable to participants, positively change knowledge and clinical team confidence, and can identify systems gaps in clinical care and program implementation. Simulation offers a reciprocal way of monitoring implementation fidelity of a family planning access initiative.Trial registrationThis project was determined to be exempt by the IRB of the University of Utah, the larger Family Planning Elevated program under which this pilot study was nested is registered at ClinicalTrials.gov Identifier: NCT03877757.

Reduction in Medicaid Rebates Paid by Pharmaceutical Manufacturers for Outpatient Infused, Injected, Implanted, Inhaled, or Instilled Drugs: The 5i Loophole.

When nonretail pharmacy sales exceed 70% of sales, manufacturers of infused, injected, implanted, inhaled, or instilled (5i) drugs are required to calculate average manufacturer price (AMP) under a different methodology than that used for drugs predominantly distributed through retail channels. Specifically, the modified methodology includes pharmacy benefit manager (PBM) rebates in the calculation of AMP for 5i drugs. The modified methodology reduces manufacturers' Medicaid rebate liability and increases net costs to the Medicaid program. The authors identified 15 5i drugs predominantly dispensed through the nonretail setting. Using 2013-2017 data from Medicaid, Medicare, SSR Health, and 340B program eligibility, they estimated differences in AMP, Medicaid rebates, and net Medicaid costs under both the standard and 5i AMP methodologies. AMP was 42% lower, on average, under the 5i methodology than under the standard methodology. From 2013-2017, Medicaid rebates under the 5i methodology were 82% lower than under the standard methodology, resulting in manufacturers of these 15 drugs reducing their Medicaid rebate liability by $1.1 billion in five years. Inclusion of PBM rebates in the calculation of AMP for 5i drugs significantly reduced Medicaid rebates, resulting in higher Medicaid spending. This may incentivize manufacturers to shift sales to nonretail channels. To remove this incentive, policy makers should consider excluding PBM rebates from the calculation of AMP for 5i drugs.

O06 University of North Carolina Charlotte Food Insecurity SNAP Initiative

<h3>Objective</h3> To develop a Supplemental Nutrition Assistance Program (SNAP) eligibility screening and application support system within a large public university <h3>Use of Theory/Research</h3> Recent research highlights food insecurity as a barrier to healthy eating and academic success among university students. Research also notes that university students are frequently struggling financially. <h3>Target Audience</h3> University students <h3>Program Description</h3> A 4-item SNAP Eligibility Screener was developed with input from partners at the University of Minnesota and the local Department of Social Services SNAP Office. Based on screener responses, if a student is deemed "potentially eligible" for SNAP they are provided information on how to apply for benefits. Once pilot testing on the screener was complete, the development team encouraged partners throughout the university to utilize the screener. The screener is now highlighted in instructor syllabi, on the university student support services website, and is being utilized by university financial aid officers when counseling students. <h3>Evaluation Methods</h3> There is an electronic record when a student completes the screener; therefore, there is a count of the number of students that completed the screener and the number that were determined to be "potentially eligible" for SNAP. When a student applies for SNAP, the university is contacted by the county social services office to verify student status. To evaluate whether "potentially eligible" students actually apply for SNAP benefits, University staff match ‘potentially eligible' students to those that applied for SNAP. <h3>Results</h3> Between October 27, 2021, and January 19th, 2022, approximately 159 students completed the SNAP Eligibility Screener. Of those 159 students, 29 students were ‘potentially eligible' for SNAP benefits. Among the ‘potentially eligible' students, 8 students have applied for SNAP benefits. <h3>Conclusions</h3> Educating students about SNAP and supporting them throughout the application process is one strategy that may lead to healthy eating and reduced food insecurity. <h3>Funding</h3> Center for Disease Control and Prevention; North Carolina Department of Health and Human Services.

Mortgage Refinancing, Consumer Spending, and Competition: Evidence from the Home Affordable Refinance Program

AbstractWe examine the ability of the government to impact mortgage refinancing activity and spur consumption by focusing on the Home Affordable Refinance Program (HARP) that relaxed housing equity constraints by extending government credit guarantee on insufficiently collateralized refinanced mortgages. Difference-in-difference tests based on program eligibility criteria reveal a significant increase in refinancing activity by HARP. More than three million eligible borrowers with primarily fixed-rate mortgages refinanced under HARP, receiving an average reduction of 1.45$\%$ in interest rate ($3,000 in annual savings). Durable spending by borrowers increased significantly after refinancing. Regions more exposed to the program saw a relative increase in non-durable and durable consumer spending, a decline in foreclosure rates, and faster recovery in house prices. Competitive frictions in the refinancing market hampered the program’s impact: the take-up rate and annual savings among those who refinanced were reduced by 10–20$\%$, with amplified effects for the most indebted borrowers.

Intensified support for juvenile offenders on probation: Evidence from Germany

AbstractThis paper studies a probation program in Cologne, Germany. The program, which has a clear rehabilitative focus, offers intensified personal support to serious juvenile offenders over the first 6 months of their probation period. To evaluate the program's impact on recidivism, we draw on two research designs. Firstly, a small‐scale randomized trial assigns offenders to probation with regular or intensified support. Secondly, a regression discontinuity design exploits a cutoff that defines program eligibility. The results suggest that the program reduces recidivism. The effect seems persistent over at least 3 years. Our evidence further indicates that the drop in recidivism is strongest among less severe offenders.

An Assessment of Program Eligibility Among Participants in Day Reporting Centers.

Day reporting centers (DRCs) vary considerably in how participant eligibility is determined and to date, there is little to no knowledge whether criteria for DRC eligibly are appropriately applied in program entrance. This study examines a statewide sample of individuals in community supervision settings and compares DRC eligibility criteria between DRC and non-DRC participants to examine differences between DRC participants and non-participants. Using a propensity score matched sample of 1,554 participants, study findings suggest that DRC participants show higher risk, need, and responsivity factors, consistent with the DRC programing model. These results suggest many individuals appear to be appropriately matched to DRCs, which may in turn, may influence their likelihood of program success, among other factors.

Can “race‐neutral” program eligibility requirements in criminal justice have disparate effects? An examination of race, ethnicity, and prison industry employment

AbstractResearch SummaryThis study assesses whether racial and ethnic disparities exist in prison industry employment and whether seemingly race‐ and ethnicity‐neutral eligibility requirements contribute to any such disparities. We examine whether there are racial/ethnic disparities in industrial prison work, the extent to which disparities are explained by administrative policies, and the conditions under which disparities are most pronounced. Using 10 years of prison administrative data from Ohio, this study employs multilevel and mediation analyses to examine the effects of race and ethnicity on the odds of working an industrial prison job. Results suggest that Black and Hispanic incarcerated persons (IPs) are less likely to work industry jobs than White IPs. The majority of this disparity stems from program requirements; however, some disparities maintain even when accounting for requirements. Black IPs who do not meet program requirements are less likely to work than White IPs who do not meet program requirements. Racial disparities are smaller in facilities with greater racial heterogeneity among correctional staff.Policy ImplicationsIn our discussion, we underscore how prison policies can contribute to racially and ethnically disparate incarceration experiences. The results suggest the importance of evaluating prison and other correctional policies that utilize selection criteria that appear race neutral but are likely to be disparate in their consequences. Moreover, policies aimed at diversifying staff may contribute to more equitable prison experiences for non‐White incarcerated people, although doing so does not directly address underlying policy problems that lead to inequalities.

Housing the Poor? A Comparative Study of Public Housing Provision in New York, Hong Kong, and Shenzhen

ABSTRACT Governments in cities and countries around the world are faced with housing affordability problems, which acutely affect lower income residents. Prior comparative work adopts a national perspective that primarily draws upon theories of the welfare state and Western political ideologies to understand government responses to social problems. However, such work often overlooks alternative political systems, the distinctive role of housing policy, and local government strategies. This article compares the provision and role of public housing across three global cities that are experiencing major housing affordability challenges: New York, Hong Kong, and Shenzhen. Based on a review of agency documents and housing and demographic data, we describe public housing policy priorities and examine how the respective governments administer public housing programs. We find each case shows a strong demand for public housing, a broad interpretation of target population, and evolving relationships between the public and private sectors. There are important differences in policy priorities, program eligibility, management, and overlap with the private housing market. The findings suggest standard frameworks may miss variation within countries and the changing role of cities in providing housing for low- and middle-income households.

Can Financial Incentives Help Disadvantaged Schools to Attract and Retain High‐Performing Teachers? Evidence from Chile

AbstractExtensive sorting of high‐performing teachers into the most advantaged schools contributes to the wide socioeconomic achievement gaps in many countries. The Chilean Pedagogical Excellence Assignment (AEP) pays bonuses to high‐performing teachers that are larger if they work at a disadvantaged school. Using a sharp regression discontinuity based on the program's eligibility rules, we estimate how the award affects where high‐performing teachers choose to work. The bonus, equivalent to 16 percent of an average annual salary, increased retention of high‐performing teachers in disadvantaged schools by 17 to 21 percentage points. In contrast, those teachers in more advantaged schools seem to use the award as a quality signal to stay or move to relatively high‐achieving schools. While the program accomplished its goal of retaining high‐performing teachers already working at disadvantaged schools, it did not achieve the objective of attracting better teachers from more advantaged schools.

The impact of cash and health insurance on child nutrition during the first 1000 days: Evidence from Ghana

Child malnutrition remains a major global public health issue, with 155 million children under five stunted and 52 million children wasted. Social protection, in the form of cash transfer programmes, has been identified as a potential nutrition-sensitive intervention to address malnutrition in early childhood. This study documents the impacts on young child nutrition outcomes and underlying determinants of a Ghanaian cash transfer programme paired with health insurance fee exemptions, targeted to pregnant women and infants under one year. We use data from a 24-month quasi-experimental impact evaluation which exploits the fact that households were selected into the programme based on a continuous programme eligibility index. Using a difference-in-difference approach, our study finds no main treatment effect on nutritional outcomes. Household-level food security improved, yet child meal frequency decreased, suggesting an important role for the intra-household allocation of resources. We conclude that cash alone is unlikely to yield impacts on young child nutrition outcomes and integrated programmes that aim to address multiple underlying determinants at the same time need to be further examined, including effects on the intra-household division of resources.