Not having health insurance has consequences for health, health care, and medical costs. Children without health insurance are more likely to be in poor or fair health, to lack a regular medical provider, and to not have visited a medical provider in the past year (6,7). They are more likely to use critical health care services and less likely to use primary and preventive health care services than are insured children (6,7). Uninsured parents often postpone seeking medical treatment for themselves and their children, which can have serious and costly consequences (8). A child treated early for uncomplicated appendicitis can be released from the hospital in 2 days, at a cost of approximately $8,000. A child admitted for a perforated appendix may have a hospital stay of 7 to 10 days, which costs an estimated $100,000 more (8).

Latinos without health insurance are more likely to use the emergency department than to visit a doctor's office (9). Unnecessary use of emergency services is responsible for high charges to the Massachusetts Health Safety Net, formerly known as the Uncompensated Care Pool, which pays for medically necessary services provided by hospitals and community health centers to low-income uninsured and underinsured residents. Costs charged to the Uncompensated Care Pool for a computed tomographic scan ranged from $359 to $4,401 in 2003 (10). In 2001, US hospitals provided $23.6 billion in uncompensated health care (11). The same year, providers submitted invoices for approximately $35 billion for which they received $30.6 billion from government sources, either through direct subsidies or reimbursement (11).

Uninsured people die prematurely and experience poorer quality of services than do insured people (12). The Institute of Medicine estimates that approximately 18,000 deaths per year are attributable to lack of health insurance (12) because uninsured people are less likely to use preventive services, to have a regular source of care, and to benefit from early treatment and diagnosis. Latinos in the United States who are younger than 65 years and who have chronic diseases such as diabetes are less connected to the health care system than members of non-Latino groups and less likely to use it effectively or to feel confident in it to manage their medical conditions (9).

Poor health literacy affects people who are older, immigrants, poor, or poorly educated (3). A recent study found that Latino parents in Boston had difficulty obtaining health insurance coverage for their children because of lack of information and misconceptions. Parents did not understand the eligibility criteria and application process for MassHealth (which administers Medicaid and other public health insurance programs for Massachusetts residents) or the Children's Medical Security Plan, which covers children who are not eligible for MassHealth, including those whose immigration status is undocumented (3). Parents also reported language barriers and the complexity of the application process as obstacles to applying (3).

Another barrier to health obtaining insurance for immigrants is their concern about immigration status (13). Some have reported being apprehensive that using health benefits may diminish their chance of gaining citizenship or their relatives' likelihood of being allowed to immigrate to the United States (13). Fear of being reported to immigration authorities by a health service provider is another obstacle identified by undocumented Latino immigrants and one that would deter them from enrolling in health insurance (14).

The program director (M.A.) posted written notices to recruit case managers in 2 East Boston public housing developments. Referrals from community agencies were also used to identify and recruit residents with leadership qualities for the program. Recommendations from community members were given high consideration. The program director interviewed and selected case managers to ensure that the mix of case managers reflected the countries of origin of Latino residents. The program director organized training and ongoing inservice education for the case managers.

The program team, consisting of case managers and the program director, visited public housing developments in East Boston, where they knocked on residents' doors and explained the LHIP. Families were invited to participate in educational sessions. The program team conducted similar outreach at community sites that are ideal for face-to-face information sharing, including bodegas, beauty salons, self-service laundries, restaurants, automobile repair shops, gas stations, and churches (14,17). All oral and written communication was available in Spanish and English.

After outreach and recruitment began, educational sessions were held on 2 evenings per month for 5 consecutive months at trusted community locations (including 2 community rooms of the housing developments and local churches) and at times convenient for participants. Child care and a meal with ethnically appropriate food were provided. The program director led the sessions in Spanish with assistance from representatives of state advocacy agencies that work with immigrants and from state officials who discussed the new Massachusetts health law (18) and the 2 new health insurance plans offered by the state, Commonwealth Care and Commonwealth Choice (18).

Before the educational sessions, attendees were interviewed to determine whether they were eligible for health insurance. The educational session lasted 2 hours. Case managers helped eligible families who wished to enroll for health insurance to apply at the end of each session. Follow-up help was provided at a local church office if participants did not have the required documentation or the application was not completed at the session. The case managers scheduled one-on-one visits with participants, when necessary, to complete applications and collect required documentation; they then sent completed forms electronically to MassHealth for coverage determination. MassHealth determines who qualifies for state entitlement programs, including Medicaid, the Children's Medical Security Plan, Commonwealth Care, or the Health Safety Net (see Appendix for details on health insurance programs). Case managers completed online applications through the Commonwealth Connector Web site (www.mahealthconnector.org) for families and individuals with an income above 300% of the federal poverty level, who were not eligible for these 4 state entitlement programs.

The LHIP established direct communication with the East Boston Community Health Center and the Boston Public Health Commission to assure ease of referral and primary care provision for newly enrolled Latinos. The LHIP also linked residents with programs that address domestic violence, senior services, food stamps, fuel assistance, and legal services.

The LHIP documented the following outcomes of its 1-year pilot:

Thirteen East Boston Latino residents were recruited and interviewed by the program director. Of the 6 chosen as case managers, 2 had medical or clinical experience, 3 had community organizing experience, and 1 was a pastor. They came from the major Latin American subgroups in Massachusetts and East Boston and included 1 Puerto Rican, 3 Dominicans, 1 Salvadoran, and 1 Colombian. All case managers worked 8 hours per week.

The MassHealth educational unit trained case managers on MassHealth and the Children's Medical Security Plan, and the LHIP program director organized research-based training on the obstacles for Latino families to enroll in health care (3). Case managers then received 1 week of supervised on-the-job training by the program director. Inservice training consisted of ongoing supervision by the program director, forums on the new Massachusetts health reform law and its Commonwealth Care program, and updates on MassHealth.

Knocking on doors at the East Boston housing developments and the face-to-face invitation to participate in the educational session at trusted community sites proved successful at attracting residents to the education and enrollment sessions. Local churches provided space for educational sessions and made referrals to the program, adding to the success of recruitment. An additional point of recruitment was the Salvadoran consulate; Salvadorans have been identified in previous studies as the most uninsured group in the East Boston neighborhood (17). The management offices of the East Boston housing development also referred families to the LHIP. Finally, word of mouth among enrolled residents brought other residents.

During the year-long pilot program, 104 of 130 adults and all 100 children were determined to be eligible and were enrolled in state-subsidized and nonsubsidized health insurance programs, the largest subgroups being Dominican and Salvadoran by country of origin and citizens and undocumented immigrants by civic status (Table 1). All children were enrolled in either MassHealth or the Children's Medical Security Plan. More than 70% of the adults signed up for health insurance programs after educational sessions. The remainder signed up during office visits to the LHIP after being referred by other participants. Twenty percent of the adults were ineligible for any type of insurance coverage, and they were assisted in receiving services through the Uncompensated Care Pool offered at their local health center or hospital (Table 2).

A total of 123 households were assisted with obtaining primary care providers and social services. Newly enrolled East Boston residents who did not have a provider were referred to the East Boston Neighborhood Health Center to choose a health care provider for their children and themselves and to be seen for primary care, if necessary. The case managers referred newly insured residents from outside the East Boston neighborhood to the Boston Public Health Commission for primary care and for additional programs when needed, such as domestic violence shelter or senior services. Case managers also electronically enrolled eligible participants into the state food stamp program, now known as the Supplemental Nutrition Assistance Program. For fuel assistance, participants were referred to a local agency that helps eligible families pay their electric and gas bills during winter; for legal representation in medical disputes, especially given the uncertainty about the new health law in Massachusetts, they were referred to Health Law Advocates, pro bono attorneys. Case managers helped residents to apply for Social Security assistance for their eligible disabled children and to enroll in citizenship classes if they wished to change their immigration status (Table 3).

The LHIP documented the numbers and characteristics of enrollees, the types of health insurance received, and referrals for health and social services (Tables 1-3). The program tracked families as they moved and maintained follow-up with nearly all participants over the course of the year to assure that they stayed enrolled in health insurance plans and that they received needed services.

We cannot generalize from this pilot intervention program in the Latino community of East Boston to other underinsured populations of racial and ethnic minorities, particularly regarding the methods and messages of outreach and recruitment. All populations with high rates of underinsurance should be reached by using models, methods, and messages that are culturally relevant. We suggest that the optimal programs to fulfill government responsibility for assuring access to state-sponsored programs are ones that arise from partnerships between a municipal health agency and community-based advocacy groups.

During the pilot program, the LHIP partnered with the Boston Public Health Commission, the Massachusetts Immigration and Refugee Advocate Coalition, Health Law Advocates, and the East Boston Neighborhood Health Center to ensure that newly insured Latinos were linked with local health providers and social and legal services and advocates. These partnerships also provide the health agencies and institutions with a culturally and linguistically competent community partner in the mutual goal of improving primary health care and social services to all community members. After the pilot program, the LHIP model was adapted by the Boston Public Health Commission for use in Safe Shops, an occupational and environmental health education and outreach program to Latino-owned automobile repair shops. The LHIP also trained Massachusetts members of the Brazilian American Association to use its model in the Brazilian community. The program continues to serve East Boston residents and was expanded in 2008 to Framingham, in suburban Boston.

Local health agencies, health care providers, and foundations with a family health mission can partner with community-based programs such as the LHIP that are more strategic, proficient, and nimble in outreach, education, and recruitment. With culturally competent partners, health agencies and providers can focus on providing effective primary care and prevention programs for newly insured residents.