Removing Barriers to Government Benefits: Link Health’s Role in Advancing Health Equity Through Expanded Enrollment

Abstract: 

Objectives. To evaluate Link Health’s role in improving federal benefit program enrollment by analyzing application trends and impact from 2022-2024.

Methods. Link Health connects eligible populations to federal benefits through in-person and remote methods. Using data from clinics in Massachusetts and Texas and remote sign-ups, we analyze enrollment trends, funding disbursed, and demographics.

Results. From 2022-2024, Link Health supported 2,362 applicants, disbursing over $2.8 million to eligible families. Application methods differed significantly by language (𝛸²=97.4, P<0.001, v=0.4), age (W=589819, P=0.03, r=0.05), state (𝛸²=11.5, P<0.001, v=0.1), and race (𝛸²=138.1, P<0.001).

Conclusions. By providing multiple enrollment options, Link Health is able to engage diverse groups, including those who might otherwise face challenges with traditional enrollment processes. This flexibility ensures broader accessibility and inclusion, ultimately reducing barriers and improving service reach for populations that may be difficult to engage through a single method. In the context of diminishing federal support and the postpandemic benefits cliff era, organizations like Link Health are critical to help individuals access such resources, which provide support across a range of health determinants.

Policy Implications. Targeted, community-based enrollment models like Link Health’s could be applied to enhance access to vital resources across the country.

INTRODUCTION

Benefit Programs in the Postpandemic Era

During the SARS-CoV-2 pandemic, the federal government’s expansion of benefit program assistance provided critical support. The American Rescue Plan increased the Supplemental Nutrition Assistance Program (SNAP) benefit, invested in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), and enhanced tax credits to help cover child care costs.¹ The Affordable Connectivity Program (ACP) subsidized internet costs, thereby improving telehealth access, which became a crucial resource during the pandemic.[2]Affordable Connectivity Program. Universal Service Administrative Company. Accessed October 21, 2024. https://www.usac.org/about/affordable-connectivity-program/ The positive effects of such programs on health and well-being offer promising opportunities to support vulnerable communities and address the "health-wealth" gap; benefit programs have been shown to reduce food insecurity, decrease emergency department (ED) visits, and increase employment.[3]Lee MM, Poole MK, Zack RM, Fiechtner L, Rimm EB, Kenney EL. Food insecurity and the role of food assistance programs in supporting diet quality during the COVID-19 pandemic in Massachusetts. Front Nutr. 2022;9:1007177. doi:10.3389/fnut.2022.1007177 Four years after the pandemic, the expiration of these temporary programs signals a looming crisis for vulnerable communities, leaving many to face the consequences of lost support. For example, as communication, education, and healthcare increasingly shifted online following the pandemic, the end of the ACP in June 2024 left many without affordable internet access, further isolating them and limiting their ability to engage in learning and preventive care.[4]Agarwal SD, Cook BL, Liebman JB. Effect of Cash Benefits on Health Care Utilization and Health: A Randomized Study. JAMA. Published online July 22, 2024:e2413004. doi:10.1001/jama.2024.13004 This loss has exacerbated the 'digital divide' and deepened health inequalities.[5]Employment. SEED. Accessed October 28, 2024. https://www.stocktondemonstration.org/employment Many other programs which provided economic support to individuals and businesses have phased out, resulting in a sudden loss of benefits that left families and communities more economically vulnerable, with notable impacts on poverty and food security across the United States.[6]The health-wealth gap. https://www.apa.org. Accessed October 28, 2024. https://www.apa.org/monitor/2013/10/health-wealth

Marginalized populations were disproportionately affected by losses of cash during the pandemic. A 2024 report in the Journal of the American Medical Association reported that employment returned to prepandemic rates by June 2020 for higher-wage workers but remained down by 13% for lower-wage workers as of December 2021[7]Koonin LM. Trends in the Use of Telehealth During the Emergence of the COVID-19 Pandemic — United States, January–March 2020. MMWR Morb Mortal Wkly Rep. 2020;69. doi:10.15585/mmwr.mm6943a3; postpandemic employment trends reflect the already existing wealth gap made worse by job loss. The authors point to evidence that unemployment and income loss has an association with poor mental health during prior economic crises, including during recessions. The Center on Budget and Policy (CBPP) examines the importance of temporary pandemic unemployment programs in relieving financial duress endured during the pandemic.[8]Roh S, Cantor J, Uscher-Pines L, Briscombe B, Baird MD. Disparities in Telehealth Use by Race and Ethnicity in a Commercially Insured Population. JAMA Health Forum. 2023;4(6). doi:10.1001/jamahealthforum.2023.1652 The initial benefit programs implemented during the pandemic via the March 2020 CARES Act and the American Rescue Plan one year later expired in September 2021, resulting in vulnerability for roughly 46 million individuals who received these unemployment benefits. The CBPP notes the exodus of benefits left some 1.4 million children at risk of falling below the poverty line.

A July 2024 survey from the Benton Institute for Broadband & Society investigated the consequences that follow the expiration of assistance programs, in particular the ACP.[9]Ringlein GV, Ettman CK, Stuart EA. Income or Job Loss and Psychological Distress During the COVID-19 Pandemic. JAMA Netw Open. 2024;7(7):e2424601. doi:10.1001/jamanetworkopen.2024.24601 A representative sample of 2,535 households with annual incomes of $50,000 or less were surveyed. Among key statistics identified in the report, the Benton Institute found that 13% of ACP households (3 million households) would cancel their internet services, while 36% (8.3 million households) would downgrade to lower-quality plans amidst the ACP’s expiration. They estimate $800 million annually in additional healthcare costs due to reduced telehealth use (with 60% of surveyed households having used their internet for telehealth in the prior three months) and increased difficulty with essential activities such as benefit renewal, communicating with a student’s school, working from home, accessing education, and communicating with local government.[10]Historic Unemployment Programs Provided Vital Support to Workers and the Economy During Pandemic, Offer Roadmap for Future Reform | Center on Budget and Policy Priorities. March 24, 2022. Accessed December 17, 2024. https://www.cbpp.org/research/economy/historic-unemployment-programs-provided-vital-support-to-workers-and-the-economy

Compounding the postpandemic 'benefits cliff,' the application process for support programs has long posed significant barriers, leading to challenges with identifying and enrolling in remaining benefit programs; eligibility criteria for each program is nuanced, enrollment applications are cumbersome, and timelines differ for verification and follow-up, ultimately resulting in program under-enrollment.[11]Leaving Money on the Table: The ACP’s Expiration Means Billions in Lost Savings. Benton Foundation. July 24, 2024. Accessed December 17, 2024. https://www.benton.org/publications/acp-expiration-means-billions-lost-savings Navigating these barriers and maximizing enrollment calls for interdisciplinary collaboration among experts in policy, technology, marketing, and healthcare. Eliminating enrollment barriers is a key strategy to enhance the effectiveness of remaining programs and support under-resourced communities as they navigate the aftermath of the SARS-CoV-2 pandemic and the loss of benefits. 

The Link Health Program

Link Health––a Boston-based nonprofit that also operates in Houston, Texas––seeks to overcome challenges with accessing federal benefits and ensure that vulnerable populations utilize available resources​. The organization's goal is to close the gap between underserved communities and economic opportunity by supporting low-income individuals as they apply for federal benefit programs. To accomplish this goal, Link Health partners with Federally Qualified Health Centers, EDs, and mobile clinics. This approach is informed by research emphasizing the critical role healthcare providers play in increasing public program utilization.[12]How To Address the Administrative Burdens of Accessing the Safety Net. Center for American Progress. May 5, 2022. Accessed October 29, 2024. https://www.americanprogress.org/article/how-to-address-the-administrative-burdens-of-accessing-the-safety-net/ A multi-pronged in-person and digital approach supports patients through the entirety of the application process, successfully integrating social and medical care.[13]Patel SR, Ruggiero DA, Roberts ET. Increasing Medicare Savings Program Enrollment—Improving Affordability of Care. JAMA. Published online October 30, 2024. doi:10.1001/jama.2024.21078 Link Health has submitted applications to the Lifeline, Medicare Savings (MSP), and Home Energy Assistance (HEAP) Programs, as well as SNAP, WIC, the ACP, the Earned Income Tax Credit, BabySteps, Transitional Aid to Families with Dependent Children, and Child Care Financial Assistance. These programs address basic needs including gas and electricity, food security, child care, and educational opportunities. For example, the Lifeline Program provides a $9.25 discount on phone and internet,[14]Urban Institute. c Published August 2023. Accessed November 12, 2024. https://www.urban.org/sites/default/files/2023-08/A%20Safety%20Net%20with%20100%20Percent%20Participation-%20How%20Much%20Would%20Benefits%20Increase%20and%20Poverty%20Decline_0.pdf SNAP offers approximately $200 per month for groceries,[15]Ganacias K, Rethy JA. Women, Infants, and Children (WIC) Enrollment: Learning From Key Informants to Enhance Utilization. Am J Public Health. 2023;113(S3). doi:10.2105/AJPH.2023.307443 and MSP assists with Medicare payments.[16]Callahan CM, Carter A, Carty HS, Clark DO, Grain T, Grant SL, McElroy-Jones K, Reinoso D, Harris LE. Building the Infrastructure to Integrate Social Care in a Safety Net Health System. Am J Public Health. 2024;114(6):619-625. doi:10.2105/AJPH.2024.307602 

The economic fallout from program cuts and the compounded challenges for individuals when programs like the ACP are phased out highlight fundamental weaknesses in the reactive nature of the benefits system. For those already facing access barriers, these changes can significantly worsen their ability to receive support as they become increasingly isolated. Link Health addresses these issues by promoting awareness and streamlining access into a single platform - without the need for increasing funding. In doing so, it demonstrates elements of a more proactive system that ensures individuals are aware of and able to access programs for which they are eligible, especially in the postpandemic era as available programs shift. 

Our objective in this study is to describe Link Health’s methods to remove enrollment barriers and its impact on the communities it serves. We explored the populations that were helped, including an analysis of demographic characteristics and differences in preferred enrollment method, the number of applicants per program, and total funds disbursed. By exploring differences across enrollment methods, we highlight how Link Health is a model to help individuals obtain essential support without requiring new funding sources, and how it is creating sustainable improvements in community well-being despite the phasing out of programs and the postpandemic benefits cliff. This analysis may be used to identify how similar organizations can mitigate obstacles to public benefits and strive for improved community health.

METHODS

Link Health Enrollment Process

Link Health’s combined in-person and digital approach increases the accessibility of federal benefit programs and supports diverse applicants' needs. The in-person model involves weekly sign-up events at health centers. Assistance is offered in multiple languages, and Patient Navigators conduct brief screenings before completing applications with patients. An artificial intelligence (AI)-enabled dashboard transfers information from one application to another, bypassing the need to fill duplicate information for multiple program applications. Completed applications are submitted for verification and follow-up. The team also distributes materials in several languages to share content about Link Health and benefit enrollment. The remote team assists in completing applications with outstanding information and in organizing text-campaigns with support from community partners. Participants can also sign-up for Lifeline, SNAP, and WIC using online forms on the Link Health website (see Appendix A for Link Health’s detailed in-person and digital enrollment process). 

Data Collection, Preparation and Descriptive Statistics 

The research protocol for this study was reviewed by an Institutional Review Board (IRB) and determined to fall outside the definition of human subjects research. As a result, this secondary analysis of Link Health operational data required no additional IRB approval prior to the commencement of the research activities.

Applicant demographic information was collected in-person at 13 clinics in Boston and four in Houston, as well as digitally, through Google Forms and a Firebase Realtime Database. Data sources were aligned, and descriptive statistics and visualizations were generated using Tableau and R Studio 4.3.1. To understand how enrollment methods differed by applicant demographics, significant differences between groups were computed using Wilcoxon rank sum test with continuity correction for the non-normally distributed continuous variable (age) and Chi-square tests for independence for categorical variables (gender, race, language, state of application) with Bonferonni corrections to adjust for multiple comparisons. It was assumed that applicants enrolling in monthly benefit programs remained in the program for one year to estimate total funds disbursed. Effect sizes were calculated to quantify the magnitude of differences across enrollment methods. Cohen’s h was used for pairwise comparisons of proportions, providing standardized differences between groups. Cramér’s v was employed to assess the strength of association between categorical variables with multiple levels. Additionally, biserial rank correlation (r) was calculated to measure the relationship between the continuous variable of age and the dichotomous enrollment method, showing a small effect (r = 0.1). These measures provide a nuanced understanding of differences and associations, complementing significance tests to better interpret the practical relevance of findings.

RESULTS

Demographic Characteristics, Application Methods, and Qualifications 

Since launching in November 2022, Link Health has facilitated applications for 2,362 individuals, resulting in 2,702 benefit program applications (many applicants applied for multiple programs). 

During the study period (November 2022 - November 2024), applicants accessed Link Health through two primary methods: 55.7% (n=1,316) applied in-person, while 44.3% (n=1,046) completed applications remotely (Table 1). A high proportion of applicants (40.6%, n=958) identified as Hispanic/Latino(a), and 15.6% (n=368) identified as Black/African American (Table 1). The distribution of program qualifications, shown in Table 1, reveals a majority of total applicants qualified via Medicaid (71.0%, n=1,678) or SNAP (26.1%, n=616). A significant portion of applicants (29.9%, n=707) preferred to communicate in Spanish (Table 1). Notably, among Spanish-speaking applicants, 444 (62.8%) applied in-person. Most enrollees were female (60.1%, n=1,419) and between the ages of 37 and 55 (38.3%, n=904). Of the 629 applicants aged 55 and over, 377 (60%) enrolled in-person.

Table 1 Link Health Demographics by Enrollment Method, 2022-2024 (N=2362)

Characteristics, n(%)	Total (N=2362)	In-Person (n=1316)	Remote (n=1046)
Race/ Ethnicity
Hispanic/Latino(a)	958 (40.6)	568 (24.0)	390 (16.5)
Black/African American	368 (15.6)	159 (6.7)	209 (8.8)
White	379 (16.0)	92 (3.9)	287 (12.2)
Asian	54 (2.3)	24 (1.0)	30 (1.3)
Unknown	536 (22.7)	452 (18.5)	84 (2.0)
Other	67 (2.8)	21 (0.9)	46 (1.9)
Preferred Language
Spanish	707 (29.9)	444 (18.8)	263 (11.1)
English	1090 (46.1)	399 (16.9)	691 (29.3)
Haitian Creole	3 (0.1)	3 (0.1)	0 (0.0)
Portuguese	2 (0.08)	2 (0.8)	0 (0.0)
Arabic	1 (0.04)	1 (0.04)	0 (0.0)
Unknown	504 (21.3)	457 (19.3)	47 (2.0)
Other	55(2.3)	10 (0.4)	45 (1.9)
Gender
Male	739 (31.3)	385 (16.3)	354 (15.0)
Female	1419 (60.1)	775 (32.8)	644 (27.3)
Nonbinary	2 (0.08)	1 (0.04)	1 (0.04)
Unknown	202 (8.6)	155 (6.6)	47 (2.0)
Age Ranges
Under 18	60 (2.5)	26 (2.0)	34 (3.3)
18-36	647 (27.4)	342 (26.0)	305 (29.2)
37-55	904 (38.3)	463 (35.2)	441 (42.2)
55 and over	629 (26.6)	377 (28.6)	252 (24.1)
Unknown	122 (5.2)	108 (8.2)	14 (1.3)
State
Massachusetts	1799 (76.2)	1047 (79.6)	752 (71.8)
Texas	536 (22.7)	267 (20.3)	269 (25.7)
Other	27 (1.1)	2 (0.2)	25 (2.6)
Qualifying Methoda
Medicaid	1678 (71.0)	979 (74.4)	699 (66.8)
Medicare	284 (12.0)	42 (3.2)	161 (15.4)
SNAP	616 (26.1)	283 (21.5)	334 (31.9)
WIC	81 (3.4)	63 (4.8)	18 (1.7)
Income	109 (4.6)	82 (6.2)	27 (2.6)
SSI	83 (3.5)	55 (4.2)	28 (2.7)
Federal Public Housing Assistance	61 (2.6)	35 (2.7)	26 (2.5)
Pell Grant	7 (0.3)	6 (0.5)	1 (0.1)
Free or Reduced Lunch	53 (2.2)	33 (0.3)	20 (1.9)
Veteran’s/Survivor’s Pension	5 (0.2)	5 (0.4)	0 (0.0)

a. Applicants may qualify for programs through multiple methods, resulting in a percentage greater than 100.

Abbreviations: SNAP, Supplemental Nutrition Assistance Program; WIC, Special Supplemental Nutrition Program for Women, Infants and Children; SSI, Supplemental Security Income.

Table 2 shows the results of Pearson’s Chi-squared tests to examine statistically significant differences in enrollment method (in-person vs remote) by gender, language, state (Massachusetts or Texas), and race. Excluding individuals whose preferred language was unknown, we found a significant difference in the enrollment method for whether someone’s preferred language was English or not, with a medium effect size (𝛸²=97.4, P<0.001, v=0.4). We found a significant difference in enrollment method by state with a small effect size (𝛸²=11.5, P<0.001, v=0.1). No significant difference was found when comparing enrollment methods across males and females (𝛸²=1.14, P=0.29, v=0.0). Table 2 also shows a statistically significant difference between in-person and remote applications when evaluated by age, with a small effect size (W=589819, P=0.03, r=0.1). Significant differences were found when comparing racial group and enrollment method (𝛸²=138.1, P<0.001). We calculated the effect size for each racial group using Cohen’s h, resulting in values of -0.37 for Hispanic participants, 0.27 for Black/African American participants, 1.08 for White participants, and 0.22 for Asian participants (Table 2). Cohen’s h values indicated a very large difference in enrollment preferences among White participants (h = 1.1) and a small-to-moderate preference for in-person enrollment among Hispanic/Latino(a) participants (h = -0.4).

Table 2. Significance Tests for Link Health Population Characteristics by Enrollment Method, 2022-2024

Variables	In-Person	Remote	Test Statistic	df	P-value	Effect Size
Race/Ethnicity, n(%)			𝛸2=138.1	3	<0.001
Hispanic/Latino(a)	568 (67.4)	390 (42.6)				h=-0.4a
Black/African American	159 (18.9)	209 (22.8)				h=0.3
White	92 (10.9)	287 (31.3)				h=1.1
Asian	24 (2.8)	30 (3.3)				h=0.2
Preferred Language, n(%)			X2 = 97.4	1	<0.001	v=0.4b
English	399 (46.4)	691 (69.2)
Other	460 (53.6)	308 (30.8)
Gender, n(%)			X2=1.1	1	0.29	v=0.0
Male	385 (64.5)	354 (66.8)
Female	775 (35.5)	644 (33.2)
State, n(%)			X2 =11.5	1	<0.001	v=0.1
Massachusetts	1047 (79.7)	752 (73.7)
Texas	267 (20.3)	269 (26.3)
Age, Median (IQR)	45 (22)	43 (26)	W = 589819		0.03	r=0.1c

1. Cohen’s h was used to estimate effect size for differences across race/ethnicity
2. Cramer’s V was used to estimate effect size for differences across language, gender, and state
3. Rank-biserial correlation was used to estimate effect size for differences across age

Conducting a post-hoc test for pairwise proportions, we found significant differences between enrollment methods across Asian and White applicants (P=0.01), Black/African American and Hispanic applicants (P<0.001), Black/African American and White applicants (P<0.001), and Hispanic and White applicants (P<0.001) (Table S1). All other group comparisons were not found to be significantly different. Figure S1 visualizes how a lower proportion of White applicants enrolled in-person relative to other racial groups.

Applicant Enrollment and Intervention Impact 

Over the study period, the pace of Link Health’s application submissions and reach has increased, particularly following an expansion of programs during Summer 2024 (Figure 1).

Figure Legend: Link Health applications and money disbursed have increased dramatically over time, particularly during concentrated efforts over the summer when Link Health expanded its online application tools and the number of programs available

In total, Link Health helped disburse an estimated $2.8 million in annual benefits between November 2022 and November 2024 to eligible individuals (Table 3). Applications for the ACP and Lifeline programs (both of which provide support for broadband connectivity) were highest at 2,234 applicants combined, with a combined $518,388 total disbursed funds. 

Table 3 Nationwide Enrollment Numbers and Money Disbursed for the Link Health Population by Program, 2022-2024 (N=2702)

Program	n (%)	Money Disbursed
HEAP	25 (0.9)	$48,750
Lifeline	1148 (42.5)	$127,428
SNAP	111 (4.1)	$333,000
ACP	1086 (40.2)	$390,960
WIC	94 (3.5)	$67,680
Kinderwait	52 (1.9)	$832,000
TAFDC	108 (4.0)	$922,752
MSP	21 (0.8)	$37,422
Babysteps	10 (0.4)	$500
GYR	47 (1.7)	$70,500
Total	2702	$2,830,992

Abbreviations: HEAP, Home Energy Assistance Program SNAP, Supplemental Nutrition Assistance Program; ACP, Affordable Connectivity Program; WIC, Special Supplemental Nutrition Program for Women, Infants and Children; TAFDC, Transitional Aid to Families with Dependent Children; MSP, Medicare Savings Program; GYR, Get Your Refund.

DISCUSSION

This descriptive study examines the demographic profile of Link Health participants and evaluates its effectiveness in connecting eligible individuals to federal benefit programs. The study analyzes enrollment trends by applicant demographics, emphasizing the need for both in-person and remote methods to improve accessibility. This work resulted in $2.8 million in annual benefits disbursed and 2,702 program applications. As pandemic-era programs end, Link Health’s hybrid model plays a critical role in proactively ensuring benefits access.

Our findings reveal significant differences in enrollment methods across racial, linguistic, age, and state demographics. This variation highlights how Link Health’s hybrid approach effectively supports individuals with diverse identities in navigating the complexities of benefit enrollment, especially those who might otherwise face barriers to access. For instance, 62.3% of Spanish-speaking applicants preferred in-person enrollment (Table 1), reflecting the importance of multilingual applications. The negative effect (h=-0.4) observed for Hispanic participants enrolling in-person suggests that their enrollment patterns differ from other groups (Table 2, Figure S1). This aligns with the finding that a significant proportion of Spanish-speaking applicants preferred in-person enrollment; such resources are crucial for non-English-speaking individuals, as they reduce language barriers, help clarify complex information, and ensure individuals receive accurate assistance tailored to their linguistic and cultural needs​.[9]Ringlein GV, Ettman CK, Stuart EA. Income or Job Loss and Psychological Distress During the COVID-19 Pandemic. JAMA Netw Open. 2024;7(7):e2424601. doi:10.1001/jamanetworkopen.2024.24601[10]Historic Unemployment Programs Provided Vital Support to Workers and the Economy During Pandemic, Offer Roadmap for Future Reform | Center on Budget and Policy Priorities. March 24, 2022. Accessed December 17, 2024. https://www.cbpp.org/research/economy/historic-unemployment-programs-provided-vital-support-to-workers-and-the-economy Older applicants also appeared to favor in-person enrollment, with 60% of applicants aged 55 years or older enrolling in-person (Table 1). This preference for in-person resources may reflect barriers to online access and digital literacy for older populations,[11]Leaving Money on the Table: The ACP’s Expiration Means Billions in Lost Savings. Benton Foundation. July 24, 2024. Accessed December 17, 2024. https://www.benton.org/publications/acp-expiration-means-billions-lost-savings reinforcing the need for diverse enrollment methods to ensure equitable access. With applications increasingly available online, sustained efforts to minimize enrollment barriers for those who may face challenges with digital literacy are essential.[12]How To Address the Administrative Burdens of Accessing the Safety Net. Center for American Progress. May 5, 2022. Accessed October 29, 2024. https://www.americanprogress.org/article/how-to-address-the-administrative-burdens-of-accessing-the-safety-net/ These findings suggest that certain demographic groups gravitate toward specific methods, indicating that a single enrollment method might not adequately serve all populations. By providing multiple enrollment options, Link Health is able to engage diverse groups, including those who might otherwise face challenges with traditional enrollment processes. This flexibility ensures broader accessibility and inclusion, ultimately reducing barriers and improving service reach for populations that may be difficult to engage through a single method. By providing hybrid services, organizations like Link Health may serve as a bridge that connects patients to services and helps mitigate negative effects of the digital divide. 

By streamlining the process of applying to multiple programs, Link Health minimizes time and effort required to apply for benefits while also increasing the community’s awareness of available programs; this is evidenced by Link Health’s having supported 2,362 individuals and its submitting a total of 2,702 applications (Table 1, Table 3). The increase in applications and programs during Summer 2024 showcases the sustainability of Link Health’s model, as it can flexibly adapt to dynamic program availability and evolving community needs (Figure 1). For example, after the ACP’s funding ended in June 2024, Link Health continued to support broadband access by facilitating applications to the Lifeline Program, ensuring individuals were not left offline. Through its flexibility and its accessible approach, Link Health serves as a buffer to benefit loss and helps vulnerable populations “weather the storm.” Providing direct community engagement and tailored support, Link Health addresses racial and age-related enrollment preferences and meets the needs of underserved groups facing barriers to benefits. Overall, this study contributes to a broader understanding of benefit programs’ beneficiaries, the impact of shifting policies on application trends, and how organizations like Link Health address enrollment challenges to better support under-resourced communities. 

PUBLIC HEALTH IMPLICATIONS

The SARS-CoV-2 pandemic revealed the need for proactive public health approaches in benefit program management. Historically, public health funding has been reactionary, relying on emergency responses rather than sustained investment, which leaves communities vulnerable to economic cycles that compromise long-term health and stability.[13]Patel SR, Ruggiero DA, Roberts ET. Increasing Medicare Savings Program Enrollment—Improving Affordability of Care. JAMA. Published online October 30, 2024. doi:10.1001/jama.2024.21078[14]Urban Institute. c Published August 2023. Accessed November 12, 2024. https://www.urban.org/sites/default/files/2023-08/A%20Safety%20Net%20with%20100%20Percent%20Participation-%20How%20Much%20Would%20Benefits%20Increase%20and%20Poverty%20Decline_0.pdf Evidence increasingly shows benefit programs have a positive impact on health outcomes. A recent study in Massachusetts found participants who received $400 per month for nine months experienced significantly fewer ED visits than those who did not receive the benefit; outpatient visits to specialists were also higher in the intervention arm, suggesting that money itself may be a driver of interaction with preventative care services and decreased emergency visits.[15]Ganacias K, Rethy JA. Women, Infants, and Children (WIC) Enrollment: Learning From Key Informants to Enhance Utilization. Am J Public Health. 2023;113(S3). doi:10.2105/AJPH.2023.307443 A review from Finkelstein et al described how the Earned Income Tax Credit and Temporary Assistance for Needy Families’ promotes recipients’ being able to afford health services, live in healthy environments and pay for nutritious food, primarily through increases in income.[16]Callahan CM, Carter A, Carty HS, Clark DO, Grain T, Grant SL, McElroy-Jones K, Reinoso D, Harris LE. Building the Infrastructure to Integrate Social Care in a Safety Net Health System. Am J Public Health. 2024;114(6):619-625. doi:10.2105/AJPH.2024.307602 Reducing barriers to enrollment in existing programs is a key public health goal that can enhance long-term health and stability in vulnerable communities, without the need for additional funding. Link Health remains dedicated to leveraging existing programs despite postpandemic benefit reductions and declining federal support, actively educating individuals about available resources and directing remaining funds to the community.

With strong evidence supporting how public assistance improves health outcomes, it is imperative people fully utilize programs, not only for population health but for the health of the economy.[11]Leaving Money on the Table: The ACP’s Expiration Means Billions in Lost Savings. Benton Foundation. July 24, 2024. Accessed December 17, 2024. https://www.benton.org/publications/acp-expiration-means-billions-lost-savings Unfortunately, barriers––such as outdated technology, complex applications, and inconsistent eligibility requirements––create administrative burdens that deter eligible individuals from accessing these resources.[11]Leaving Money on the Table: The ACP’s Expiration Means Billions in Lost Savings. Benton Foundation. July 24, 2024. Accessed December 17, 2024. https://www.benton.org/publications/acp-expiration-means-billions-lost-savings[12]How To Address the Administrative Burdens of Accessing the Safety Net. Center for American Progress. May 5, 2022. Accessed October 29, 2024. https://www.americanprogress.org/article/how-to-address-the-administrative-burdens-of-accessing-the-safety-net/ For example, 40% of those eligible for SNAP reported their being deterred from applying by the required paperwork.[11]Leaving Money on the Table: The ACP’s Expiration Means Billions in Lost Savings. Benton Foundation. July 24, 2024. Accessed December 17, 2024. https://www.benton.org/publications/acp-expiration-means-billions-lost-savings Time spent on paperwork is staggering; in fiscal year 2017, Americans collectively spent 11.5 billion hours fulfilling paperwork requirements from federal agencies alone, averaging 45 hours per adult.[12]How To Address the Administrative Burdens of Accessing the Safety Net. Center for American Progress. May 5, 2022. Accessed October 29, 2024. https://www.americanprogress.org/article/how-to-address-the-administrative-burdens-of-accessing-the-safety-net/ Additionally, individuals who work nonstandard jobs (i.e., gig workers) face these administrative burdens at disproportionate levels, despite being more likely to benefit from enrollment.[12]How To Address the Administrative Burdens of Accessing the Safety Net. Center for American Progress. May 5, 2022. Accessed October 29, 2024. https://www.americanprogress.org/article/how-to-address-the-administrative-burdens-of-accessing-the-safety-net/ The time and resources needed to complete paperwork, interviews, and phone calls is extensive. This so-called “compliance cost” compounds “learning costs” associated with the complexity of navigating enrollment systems, as well as “psychological costs,” i.e., the stigmatization those receiving assistance experience.[7]Koonin LM. Trends in the Use of Telehealth During the Emergence of the COVID-19 Pandemic — United States, January–March 2020. MMWR Morb Mortal Wkly Rep. 2020;69. doi:10.15585/mmwr.mm6943a3

Though administrative burdens are often framed as methods to reduce fraud, these hurdles disproportionately impact specific populations and drive health inequities; applications in inaccessible languages, the need for a physical address for verification, and difficulties recertifying for programs fall harder on low-income households and safety-net participants including women, people of color, people with disabilities, and LGBTQ communities.[11]Leaving Money on the Table: The ACP’s Expiration Means Billions in Lost Savings. Benton Foundation. July 24, 2024. Accessed December 17, 2024. https://www.benton.org/publications/acp-expiration-means-billions-lost-savings[14]Urban Institute. c Published August 2023. Accessed November 12, 2024. https://www.urban.org/sites/default/files/2023-08/A%20Safety%20Net%20with%20100%20Percent%20Participation-%20How%20Much%20Would%20Benefits%20Increase%20and%20Poverty%20Decline_0.pdf Such barriers have resulted in only about half the women and children eligible for WIC actually enrolling in the program, despite consistently and rapidly increasing rates of food insecurity.[14]Urban Institute. c Published August 2023. Accessed November 12, 2024. https://www.urban.org/sites/default/files/2023-08/A%20Safety%20Net%20with%20100%20Percent%20Participation-%20How%20Much%20Would%20Benefits%20Increase%20and%20Poverty%20Decline_0.pdf[15]Ganacias K, Rethy JA. Women, Infants, and Children (WIC) Enrollment: Learning From Key Informants to Enhance Utilization. Am J Public Health. 2023;113(S3). doi:10.2105/AJPH.2023.307443 Reducing administrative burdens and simplifying processes for distributing funds could greatly alleviate poverty. According to a report by the Urban Institute, if everyone eligible for specific assistance programs were to receive benefits, overall poverty would decrease by 31%, and child poverty would fall by 44%.[15]Ganacias K, Rethy JA. Women, Infants, and Children (WIC) Enrollment: Learning From Key Informants to Enhance Utilization. Am J Public Health. 2023;113(S3). doi:10.2105/AJPH.2023.307443 

Link Health stands out by its integrating successful features of other benefit enrollment programs into a single platform. Programs like Benefits Data Trust, which assisted 1.3 million households before ceasing operations in 2024,[12]How To Address the Administrative Burdens of Accessing the Safety Net. Center for American Progress. May 5, 2022. Accessed October 29, 2024. https://www.americanprogress.org/article/how-to-address-the-administrative-burdens-of-accessing-the-safety-net/ Uno Health, which provides a simplified online qualification process,[14]Urban Institute. c Published August 2023. Accessed November 12, 2024. https://www.urban.org/sites/default/files/2023-08/A%20Safety%20Net%20with%20100%20Percent%20Participation-%20How%20Much%20Would%20Benefits%20Increase%20and%20Poverty%20Decline_0.pdf[11]Leaving Money on the Table: The ACP’s Expiration Means Billions in Lost Savings. Benton Foundation. July 24, 2024. Accessed December 17, 2024. https://www.benton.org/publications/acp-expiration-means-billions-lost-savings and Benefitscheckup.org,[15]Ganacias K, Rethy JA. Women, Infants, and Children (WIC) Enrollment: Learning From Key Informants to Enhance Utilization. Am J Public Health. 2023;113(S3). doi:10.2105/AJPH.2023.307443 which increases awareness of available programs, all serve as essential tools.[15]Ganacias K, Rethy JA. Women, Infants, and Children (WIC) Enrollment: Learning From Key Informants to Enhance Utilization. Am J Public Health. 2023;113(S3). doi:10.2105/AJPH.2023.307443[16]Callahan CM, Carter A, Carty HS, Clark DO, Grain T, Grant SL, McElroy-Jones K, Reinoso D, Harris LE. Building the Infrastructure to Integrate Social Care in a Safety Net Health System. Am J Public Health. 2024;114(6):619-625. doi:10.2105/AJPH.2024.307602 However, Link Health offers a wide scope and sustainable model through combined digital and in-person outreach, streamlined qualification screenings, and multi-program applications, ensuring broader benefit enrollment and reducing barriers for those who may otherwise be overlooked. This comprehensive approach uniquely equips Link Health to address enrollment challenges.

Link Health is expanding its work across state lines. Policy scans comparing assistance program eligibility and accessibility are conducted to understand how benefits are utilized around the country. States vary in their eligibility screenings, income and asset determinations, and application processes. Comparisons of these characteristics identify overlap and provide the basis to develop standardized screening tools and to replicate strategies employed in Boston and Houston. Some organizations, such as Uno Health, have integrated benefit applications across state lines, empowering individuals in more than ten states to complete a screening, learn about benefits and apply, all within a single portal.[7]Koonin LM. Trends in the Use of Telehealth During the Emergence of the COVID-19 Pandemic — United States, January–March 2020. MMWR Morb Mortal Wkly Rep. 2020;69. doi:10.15585/mmwr.mm6943a3 Utilizing such a tool or integrating it into popular electronic health records like Epic could be transformative in efforts to streamline benefit enrollment and merge what is traditionally viewed as social or community health work with clinical medicine.

However, in-person or hybrid models of engagement are critical for success. Disclosing identifying information to state and federal agencies can be a stressful process, particularly for those from marginalized communities. Shifting U.S. policy on citizenship compounds these concerns. Live-time support is needed to address these worries, as well as to answer questions about how signing-up for one benefit may or may not impact one’s enrollment in another. Face time with trained Patient Navigators encouraging applications helps defeat stigma associated with sign-ups. In-person assistance could result in more accurate submissions, as well.

An existing obstacle to cash assistance receipt is the sheer volume of application processing by understaffed agencies. The greater the number of community-based organizations partnering with administering entities such as the Department of Transitional Assistance[9]Ringlein GV, Ettman CK, Stuart EA. Income or Job Loss and Psychological Distress During the COVID-19 Pandemic. JAMA Netw Open. 2024;7(7):e2424601. doi:10.1001/jamanetworkopen.2024.24601 and Your Texas Benefits,[12]How To Address the Administrative Burdens of Accessing the Safety Net. Center for American Progress. May 5, 2022. Accessed October 29, 2024. https://www.americanprogress.org/article/how-to-address-the-administrative-burdens-of-accessing-the-safety-net/ the more support these benefits administrators receive, increasing the likelihood of application approvals. These organizations can continue to ally themselves with community partners through monetary incentives for accurate submissions and promotion. While digital avenues help address scalability, the onus is on healthcare administrators to find actionable means of implementing benefit sign-up in their hospitals, health centers, and offices in a manner that promotes both accurate submissions and attentiveness to the applicant.

Data-driven insights into community needs and enrollment trends can help stakeholders optimize benefit enrollment, ultimately promising sustained support for vulnerable populations before they fall victim to the aforementioned barriers. While Link Health has made in-roads completing applications for programs administered in Massachusetts and Texas, continued investigation into other states’ enrollment policies will make its work more applicable across the United States. This relies on finding niche rules that allow, for instance, the submission of multiple applications or the ability to leverage ex parte eligibility, which promotes sign-ups for benefits addressing more than just one need.[13]Patel SR, Ruggiero DA, Roberts ET. Increasing Medicare Savings Program Enrollment—Improving Affordability of Care. JAMA. Published online October 30, 2024. doi:10.1001/jama.2024.21078 Challenges that will need to be overcome include state-by-state variation in benefit administration, eligibility, online availability, and verification timelines.[12]How To Address the Administrative Burdens of Accessing the Safety Net. Center for American Progress. May 5, 2022. Accessed October 29, 2024. https://www.americanprogress.org/article/how-to-address-the-administrative-burdens-of-accessing-the-safety-net/ 

The Future of Federal Benefit Enrollment

To build a resilient and equitable society, federal benefits must be recognized as pivotal components of the public health infrastructure, not merely crisis response tools. While consistent investment in public health funding and benefit programs would be ideal actions, simplifying applications and expanding—or at least not restricting—eligibility could still make a significant impact in strengthening America’s safety net. Organizations like Link Health offer a model for sustainable and streamlined program enrollment without having to increase funding or significantly alter policy. Link Health’s partnership model––embedding services within community health centers, offering in-person and digital tools, and promoting programs that target determinants of health––facilitates a pathway forward to accessible, effective, and efficient benefit allocation. Policymakers should draw inspiration from these models to drive reforms and forge partnerships that expand the reach of support services. 

Link Health’s efforts could be met with challenges in coming days. Medicaid enrollment is an access point for applying for benefits, as it may be used as a proxy for income (roughly 130% of the federal poverty level). Importantly, previous studies have shown Medicaid enrollment efforts to be associated with increased enrollment in other public programs, such as SNAP and WIC, highlighting the need for coordinated efforts for enrollment.[15]Ganacias K, Rethy JA. Women, Infants, and Children (WIC) Enrollment: Learning From Key Informants to Enhance Utilization. Am J Public Health. 2023;113(S3). doi:10.2105/AJPH.2023.307443 If more stringent eligibility requirements are proposed, this could have significant repercussions for marginalized communities.[16]Callahan CM, Carter A, Carty HS, Clark DO, Grain T, Grant SL, McElroy-Jones K, Reinoso D, Harris LE. Building the Infrastructure to Integrate Social Care in a Safety Net Health System. Am J Public Health. 2024;114(6):619-625. doi:10.2105/AJPH.2024.307602 Individuals in need of benefits may not own an internet-enabled device, cannot afford transportation, or are less likely to open paper mail. Limiting access to Medicaid with more rigorous asset determinations will result in heightened administrative burden and loss of coverage for many, further complicating access to benefit programs.[16]Callahan CM, Carter A, Carty HS, Clark DO, Grain T, Grant SL, McElroy-Jones K, Reinoso D, Harris LE. Building the Infrastructure to Integrate Social Care in a Safety Net Health System. Am J Public Health. 2024;114(6):619-625. doi:10.2105/AJPH.2024.307602 Based on the needs identified in Link Health’s service areas, along with growing literature demonstrating the effectiveness of public assistance in influencing health outcomes, creating more roadblocks to Medicaid enrollment, and subsequently benefit enrollment, will be injurious for community health and ultimately drive up costs for insured patients.[15]Ganacias K, Rethy JA. Women, Infants, and Children (WIC) Enrollment: Learning From Key Informants to Enhance Utilization. Am J Public Health. 2023;113(S3). doi:10.2105/AJPH.2023.307443[16]Callahan CM, Carter A, Carty HS, Clark DO, Grain T, Grant SL, McElroy-Jones K, Reinoso D, Harris LE. Building the Infrastructure to Integrate Social Care in a Safety Net Health System. Am J Public Health. 2024;114(6):619-625. doi:10.2105/AJPH.2024.307602[13]Patel SR, Ruggiero DA, Roberts ET. Increasing Medicare Savings Program Enrollment—Improving Affordability of Care. JAMA. Published online October 30, 2024. doi:10.1001/jama.2024.21078

Ultimately, the goal must be to create a benefit system that is proactive rather than reactive, providing consistent support that prevents crises rather than responding to them. By learning from both the successes and gaps in the pandemic response, the government can build a more robust, equitable safety-net that empowers all Americans to achieve better health and stability.

Limitations 

While the descriptive nature of the study identifies useful patterns and associations, it does not establish causal relationships between Link Health's initiatives and outcomes in benefit enrollment or economic well-being. Additionally, the data included within this study was self-reported by applicants and may be subject to recall bias. These data are also limited in geographic scope, with a focus on a subset of participants within regions served by Link Health, Houston and Boston, thus limiting the generalizability of results to broader populations and states with differing benefit regulations. Although our study sample effectively represented Hispanic/Latino(a) participants, other minoritized communities, such as Asian and American Indian or Alaska Native participants, were less represented and further study among pools of participants with greater racial and ethnic diversity would be beneficial. Lastly, in the future, including long-term follow-up information and health data from in-person clinics could help assess the sustained impact of Link Health’s interventions on benefit enrollment and health impacts over time.

CONCLUSION

Link Health stands out with its innovative, patient-first model that blends in-person and digital support. By offering multilingual resources, a single streamlined application dashboard, and both virtual and on-the-ground assistance, it transforms a traditionally burdensome process into something accessible. In a world where benefits systems have been reactive and fragmented, Link Health proactively addresses these gaps, making it a powerful tool for communities navigating an increasingly unstable benefits landscape.

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12. How To Address the Administrative Burdens of Accessing the Safety Net. Center for American Progress. May 5, 2022. Accessed October 29, 2024. https://www.americanprogress.org/article/how-to-address-the-administrative-burdens-of-accessing-the-safety-net/
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15. Ganacias K, Rethy JA. Women, Infants, and Children (WIC) Enrollment: Learning From Key Informants to Enhance Utilization. Am J Public Health. 2023;113(S3). doi:10.2105/AJPH.2023.307443
16. Callahan CM, Carter A, Carty HS, Clark DO, Grain T, Grant SL, McElroy-Jones K, Reinoso D, Harris LE. Building the Infrastructure to Integrate Social Care in a Safety Net Health System. Am J Public Health. 2024;114(6):619-625. doi:10.2105/AJPH.2024.307602
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Supplemental Material: Appendix A

Additional Context on Link Health Enrollment Methods

In-Person Enrollment

In health centers in under-resourced communities of Boston and Houston, undergraduate volunteers (“Patient Navigators”) screen visitors and patients for eligibility. Patient Navigators station at clinics (typically in high traffic areas such as the lobby) and community events, where they distribute brochures with information regarding Link Health and current federal benefit programs. Brochures and posters are offered in English, Spanish, and additional languages to ensure accessibility. Patient Navigators directly approach patients to initiate conversation about Link Health, screen patients for program eligibility, and identify those who are eligible and interested in enrolling into a benefit program. Screening questions focus on Medicaid enrollment, children’s ages, and social security numbers (which are not saved for patient privacy). If applicants are uneasy about sharing specific information in the clinical setting, they are invited to provide these details to program administrators when they are contacted for verification interviews. However, to increase the odds of enrollments and decrease workload on program administrators, Link Health’s team works with applicants to complete applications as thoroughly and accurately as possible. 

Basic demographic information is stored securely in a Firebase Realtime Database. This artificial intelligence (AI)-enabled dashboard minimizes redundancy by transferring information from one application to another, thus bypassing the need to ask the same questions. This design streamlines a process that can be tiring for applicants. Applicants can complete sign-ups for several programs in well under 30 minutes, from initial screening to submission. Link Health also collaborates with an organization specializing in AI-enabled, HIPAA-compliant translation tools. Their application is updated based on circumstances team members encounter, including the addition of new languages and dialects and general improvements in functionality. The organization also emphasizes having posters and handouts translated in several languages to increase awareness of benefits. After applications are submitted, the administering organization (such as the Department of Transitional Assistance, which administers the SNAP and Transitional Aid to Families with Dependent Children) receives the forms and follows-up with the individual for verification if necessary. 

Remote Enrollment

In addition to its in-person assets, Link Health’s remote infrastructure enables applicants to complete applications via text-message. Link Health-affiliated clinics send an initial message to patients to screen for interest in enrolling into one or more federal benefit programs.  Remote Patient Navigators respond to those who indicate interest by offering additional information about the benefit program and sending the patient a link to a secure Google Form to collect information similar to the in-person enrollment process. After the patient completes the form, the Patient Navigator initiates a federal program account and shares login credentials with the patient, allowing them to finalize their application by inputting remaining information. In the event that the patient does not respond to the initial text message, the Patient Navigator sends a follow-up message 15-30 minutes later. Patients also have the option to speak to a Patient Navigator via a secure phone line, ensuring information remains protected. With personalized, digital conversations, applicants can interact with the team within the comfort of their homes to complete applications for WIC, SNAP, and the Lifeline Program. Remote support has several advantages: it removes ambiguity associated with signing-up in-person with a stranger and in a public setting; the applicant is supported through the process, ensuring a higher likelihood of enrollment, and it provides an additional means for sign-up, which the organization has identified as preferred among certain demographics. 

Link Health has also trialed targeted text-campaigns for remote enrollment . Utilizing a preexisting database of potentially eligible patients, a partnering Federally Qualified Health Center sends an introductory message to selected patients. The message will include an automated link that, when clicked, guides patients to open a new text conversation. After the patient initiates the conversation, a Link Health RemotePatient Navigator responds to the patient, verifying eligibility, and sending a form for the patient to complete. If the patient is eligible, the Link Health team completes the enrollment on the backend, streamlining this paperless process. Text-campaigns have been directed at thousands of patients at a time

Supplemental Figures

Table S1. Matrix of Pairwise Comparison of Proportions by Racial Group Across Enrollment Method

Racial Group	Asian, p-value	Black/African American, p-value	Hispanic, p-value
Asian	-	-	-
Black/African American	0.98	-	-
Hispanic	0.88	<0.001	-
White	0.01	<0.001	<0.001