Does Medicaid mean poorer care?


Although low-income families gained greater access to private insurance since the passage of the Affordable Care Act, a new study urges caution for policymakers looking to replace public programs that outshine private insurance for children’s healthcare.

The debate over the fate of publicly funded health programs is constant, but a study reveals that Medicaid may just be the premier coverage for children.

In a study of more than 80,000 children spanning a decade, researchers from the University of Pennsylvania in Philadelphia and Johns Hopkins University in Baltimore, Maryland found that children who received care through Medicaid had better medical preventive and dental coverage, fewer out-of-pocket costs, and no more trouble accessing care than children who received care through private insurance.

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“It is not that surprising that Medicaid and Children’s  Health Insurance Program (CHIP) were perceived better in terms of access to care than even private insurance,” says lead report author David Rubin, MD, MSCE, professor of pediatrics at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia and director of the PolicyLab at the Children’s Hospital of Philadelphia. “The commercial/private market of health insurance, through increased cost-sharing, and also more recently tiering of provider networks within their plans, may be creating more barriers at this point for access to care than Medicaid or CHIP, in which such practices are less common. Medicaid and CHIP also prioritize a full suite of essential benefits for children that are not as clearly defined in private plans.”

Data gleaned from the National Survey of Children’s Health were used to compare access to and use of healthcare services provided through Medicaid, CHIP, private insurance, and among the uninsured between 2003 and 2012. Researchers studied the healthcare usage of more than 80,000 children: 57.3% of which had private insurance; 13.6% had Medicaid; 18.4% had CHIP; and 10.8% were uninsured.

The study revealed that 88% of children with Medicaid and CHIP had access to preventive medical care; 80% of those insured with Medicaid had dental coverage; and 77% with CHIP had dental coverage compared to 83% of privately insured children with preventive medical coverage and 73% with dental coverage.

Researchers also found that in each payer group, there were challenges in accessing specialty care-as many as 1 in 4 children had difficulty seeing a specialist. The challenges were even greater for children insured under the CHIP program and privately insured children with special healthcare needs-28% and 29%, respectively, reported having problems seeing a specialist.

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Prior to the enactment of the Affordable Care Act (ACA) in 2010, low-income families could receive subsidized healthcare for their children through Medicaid or CHIP. Now, these families can also use qualified health plans (QHPs), which are sold on federal and state insurance exchanges with subsidies for families with incomes of up to 400% of the federal poverty level. Nearly 40% of children in the United States live in households with incomes between 100% and 300% of the federal poverty level, according to the report, and while ACA gave those families another coverage option, there is debate as to whether these and other private insurance programs-which some pundits had hoped might replace the CHIP program that was recently renewed through 2017-provide equivalent coverage to Medicaid and CHIP.

“The high reported rates of preventive care receipt and perception of Medicaid and CHIP coverage meeting children’s needs, together with concerns about limited access and increased cost sharing in private plans, might caution against calls for expanded private (ie, QHP) coverage for children and substantiate advocacy for extending CHIP coverage beyond 2017,” the report states. “However, this study uncovered some challenges in access to services and specialty care for both children with CHIP coverage and privately insured children with special health care needs. …These findings suggest that Medicaid might serve children in families with low to moderate incomes better than other coverage types.”

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Despite the common perception that patients with federally or state-funding healthcare have trouble finding physicians, the report found that caregivers faced challenges see healthcare providers across the board-82% of caregivers of children with Medicaid reported problems, along with 83% of caregivers of children with private insurance, and 84% of caregivers of children with CHIP. Twenty percent of caregivers of children with Medicaid and 26% with CHIP reported actually becoming frustrated with trying to obtain healthcare services for a child, but things were not much better for caregivers of children with private insurance where 21% to 24% reported frustration. Caregivers of children with CHIP were more likely to report their frustrations than those with Medicaid plans, according to the report.

Unmet medical needs were uncommon-only 2%-for children covered by health insurance, but were not much worse in the other groups. Only 2% to 3% of children with Medicaid had unmet health needs, according to the study, as well as 3% to 4% of children covered under CHIP. Uninsured children had the highest rate of unmet health needs at 8% to 12%. Figures were similar for dental care, with 78% of children covered under Medicaid and CHIP reporting their needs were met, compared to 73% of insured children.

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Care coordination and family-centered care rates were similar for each payer type, but took a nosedive for uninsured children, according to the report. Medicaid rates were 72%; CHIP was 68%; and 70% of children with private insurance received those services, while only 47% of uninsured children received care coordination of family-centered care.

Private insurance is also more costly, and not just when it comes to paying the premium. The study found that 77% of caregivers of children with private insurance had the highest prevalence of out-of-pockets costs compared with 26% of children with Medicaid and 38% of children with CHIP.

Children with special healthcare needs also seem to fare better with public health programs. Slightly fewer caregivers of children with special needs reported having problems accessing caregivers when they were insured by Medicaid (20%) and CHIP (25%), compared to private insurance (26% to 33%). Significantly fewer caregivers reported having needs met through private insurance (63%) in comparison to CHIP (73%) and Medicaid (76%), and 36% of caregivers of privately insured children with special needs reported frustration in obtaining services compared to 28% of those insured through Medicaid. Caregivers of children with special needs who were privately insured also paid substantially more, with 80% reported out-of-pocket costs compared with 40% of CHIP caregivers and 23% of Medicaid.

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The report urges careful consideration of any future policy changes to children’s health programs, and Rubin says pediatricians should stay abreast of changes and the challenges their patients face.

“The general pediatrician will need to be aware of the increasing barriers for families to accessing care, and particularly subspecialty care, among the families they serve. That will require them to probably care for more complex needs directly in the medical home and think about broader strategies to link families with the services they need,” Rubin says. “In an environment when families are not being asked to take on a greater amount of cost-sharing in order to access services, they will need to be more direct and transparent in their conversations with families about these issues. Finally, as Medicaid and CHIP grow and serve more and more children, I think that providers should be mindful of the values of these programs as perceived by families, and they should more actively participate in the advocacy around insuring that they remain strong vehicles to optimizing care for children.”

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