A Text Message Outreach Intervention to Increase Health Insurance Enrollment for Self-Pay Patients

Self-pay patients may be unaware of their eligibility for health insurance coverage through government or hospital-based medical assistance programs.

We aimed to evaluate the effect of behaviorally informed text message outreach on insurance enrollment among self-pay patients discharged from the emergency department (ED) at a safety-net hospital.

We emulated a single-arm trial with a historical comparison. Our eligible population included self-pay ED patients aged 18-64 years who were discharged between October 31 and November 24, 2022 (outreach group) or between April 1 and July 31, 2022 (historical comparison). We used entropy balancing weights to adjust for baseline characteristics and estimated overall and race/ethnicity-specific risk ratios (RR), risk differences (RD), and 95% confidence limits (CL) for the effect of the text outreach on insurance enrollment.

The study population comprised 748 patients in the intervention and 6199 in the comparison group. The median age was 36 years (interquartile range=28-47), 58% were male, and 65% were racial/ethnic minorities. Overall outreach effect on any coverage enrollment (RR=1.4, 95% CL: 1.2, 1.6; RD=7.1%, 95% CL: 3.7%, 10%) was larger than the effect on hospital-based medical assistance program and Medicaid enrollment (RR=1.2, 95% CL: 1.0, 1.4; RD=2.7%, 95% CL: -0.24%, 5.7%). The latter effect was largest in the Hispanic population.

Our results suggest behaviorally informed text outreach increases insurance enrollment among self-pay patients discharged from the ED at a safety-net hospital and may complement broader strategies to increase health insurance enrollment. Future studies should compare different text message strategies.