Public health insurance programs often get a bad rap, despite a growing positive evidence base on their patient care, quality and outcomes. Earlier this month, another study emerged that found Medicaid and the Children’s Health Insurance Program not only outperform private insurance when it comes to children’s preventive care, they can serve as a model of comprehensive children’s coverage.
Published in JAMA Pediatrics, the study is based on data from the U.S. National Surveys of Children’s Health between 2003 and 2012 — a sample of more than 80,000 children up to age 17 living in households with incomes between 100 percent and 300 percent of the federal poverty level (low to moderate income). The researchers compared health care access, quality and cost outcomes in four categories: Medicaid, CHIP, private insurance and no insurance. They found that for kids in Medicaid and CHIP, 88 percent had access to preventive medical care, compared to 83 percent among children with private insurance. There was a similar trend regarding preventive dental care. The study also reported that 78 percent of caregivers of kids enrolled in Medicaid and CHIP reported a perception that their insurance always met their needs, versus 73 percent of parents with private insurance.
Study author Amanda Kreider, who helped conduct the study during her time as a research associate at PolicyLab at Children’s Hospital of Philadelphia, said the findings are particularly relevant as some decision-makers have questioned the need for robust public health insurance programs now that the Affordable Care Act (ACA) is law. Indeed, earlier this year, many child health advocates were concerned that members of Congress wouldn’t act fast enough to reauthorize CHIP’s funding, which was set to expire in September. Fortunately, the funding was reauthorized, but only through 2017. Throughout that debate, advocates noted that due to some eligibility glitches in the ACA, if CHIP disappeared, many children would simply be left without any insurance. And many of those who switched to private insurance would likely experience a worse quality of care.
“Any measure to move low- and moderate-income kids to (health insurance) exchange plans would need to address access and cost and not be too hasty in devaluing these public plans,” Kreider, now a PhD student in health policy at Harvard, told me. “We might consider the outcomes in Medicaid a benchmark for other plans.”
The JAMA Pediatrics study found that families with privately insured children were much more likely to experience out-of-pocket costs, at 77 percent, than caregivers of children in Medicaid, at 26 percent, and CHIP, at 38 percent. About 20 percent of caregivers with kids in Medicaid reported frustration in receiving health care services, compared to 23 percent for privately insured children and 26 percent for kids in CHIP.
About 70 percent of study participants in all three insurance plans experienced care coordination. Caregivers of kids across all three insurance types reported similar rates of satisfaction with the ability to see needed health care providers as well. Difficulties in accessing specialty pediatric care popped up across the plans, however such challenges were more pronounced among kids with private insurance and those in CHIP. Not surprisingly, children with no insurance were much less likely than insured children to receive preventive care or have a usual source care.
Kreider said that the specialty care findings were somewhat of a surprise, adding that future research is needed to tease out the contributors to specialty care barriers. Kreider and co-authors Benjamin French, Jaya Aysola, Brendan Saloner, Kathleen Noonan and David Rubin write:
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 coverage for children and substantiate advocacy for extending CHIP coverage beyond 2017. 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. Although the etiology of these challenges is not well understood, these findings suggest that Medicaid might serve children in families with low to moderate incomes better than other coverage types.
Kreider said while her study doesn’t reveal the exact mechanisms that led to Medicaid’s positive reviews — for example, what exactly made access to preventive care easier for children with Medicaid — she noted that unlike marketplace plans, pediatric benefits under Medicaid are extremely well defined. In fact, while insurers participating in the new health insurance exchanges are required to offer certain essential health benefits, such as pediatric care, such benefits are not consistently defined across the country. The study cited a recent review of state benchmark plans that found no plan had a definition of pediatric services.
“What we’re seeing is that Medicaid does a great job for kids,” Kreider told me. “These programs are really providing high value for kids and I think that’s something people can get behind.”
Combined, Medicaid and CHIP provide care to more than 43 million children, including half of all low-income children in the U.S. To request a full copy of the study, visit JAMA Pediatrics.
Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.