Medicaid for children: federal mandates, welfare reform, and policy backsliding

The 1996 federal welfare reform law delinked Medicaid enrollment from welfare participation. This paper estimates the impact of welfare reform on children's Medicaid enrollment using a methodology that both adjusts for income and other demographic differences over time and across states, and provides income-specific estimates of enrollment. The results indicate large enrollment declines: Between 1995 and 1998, enrollment probabilities for children in families with no income declined from 81 percent to 68 percent, while at half the poverty line, the decline was from 61 percent to 53 percent. This implies that 926,000 to 1.37 million fewer children were enrolled after welfare reform. At the state level, Medicaid declines and welfare reform were strongly associated, with only a few states succeeding in preserving children's Medicaid coverage.     

Churning in Medicaid managed care and its effect on accountability

There is concern that churning in Medicaid excludes children from the accountability system for managed care because they may not meet the one-year continuous enrollment requirement. This study explores the effect of churning in measuring childhood immunization coverage rates under the current accountability system. Data were collected from administrative databases at the Centers for Medicaid and Medicare Services and 12 states with high Medicaid managed care penetration. On average in the 12 states only 39% of the children enrolled in one specific managed care plan met the continuous enrollment requirement. However, Centers for Medicaid and Medicare Services data showed that 78% of children were enrolled in Medicaid (but not the same plan) continuously for 12 months. Both plan-specific rates and overall Medicaid rates varied greatly across the states. Policies that result in churning mean that many vulnerable children fall outside of the accountability structure intended to assure that they receive necessary services.     

Differences in Use of Health Services Between White and African American Children Enrolled in Medicaid in North Carolina

Objectives: Racial differences in health status and use of health services persist in the United States and are not completely explained by differences in socioeconomic status. This study examines differences in use of health services between White and African American children enrolled in Medicaid, controlling for other factors that affect service use. We make comparisons for use of primary preventive services, diagnosis and treatment of selected common childhood illnesses, and Medicaid expenditures. Methods: We linked Medicaid enrollment records, Medicaid paid claims data, and data on use of child WIC services to birth certificates for NorthCarolina children born in 1992 to measure use of health services and Medicaid expenditures by race for children ages 1, 2, 3, and 4. Logistic and Tobit regression models were used to estimate the independent effect ofrace, controlling for other variables such as low birth weight, WICparticipation, and mother's age, education, and marital status. Since allchildren enrolled in Medicaid are in families of relatively low income, racial differences in socioeconomic status are partially controlled.Results: African American children had consistently lower Medicaidexpenditures and lower use of health servicesthan did White children,after statistically controlling for other maternal and infantcharacteristics that affect health service use, including child WICparticipation. For example, total annual Medicaid expenditures were $207–303 less for African American children than for White children,controlling for other variables. African America children were significantly less likely to receive well-child and dental services than were White children. Conclusions: African American children enrolled in Medicaid use healthservices much less than White children, even when controlling forsocioeconomic status and other factors that affect service use. Linkingstate administrative databases can be a cost-effective way of addressingimportant issues such as racial disparities in health service use.     

Mental Health Services for Children in Large, Employer-Based Health Plans, 1999

This study examines 1999 data from Medstat's MarketScan database of privately insured employees of US firms and their dependents. Of enrolled children and adolescents ages 2-18, 6.6% had claims for mental health services. Average outpatient expenditures per user were $651. Of children/adolescents with claims for mental health services (MH claimants), 3.4% had inpatient MH services, with an average length of stay of 8.9 days and average MH-related inpatient expenditure per user of $7,048. One half of MH claimants who had pharmacy benefit data had claims for psychotropic medications, with average expenditures per user of $328. Whereas children/adolescent mental health users comprised 8.3% of all service users, expenditures for their care were 20.5% of all service expenditures for children/adolescents in private health plans. Results also highlight the importance of including data on psychotropic medication in analysis of children's MH services utilization, as well as the need to consider the use of psychotropic medications among children/adolescents who do not utilize other MH services.     

A Comparative Study of Mortality Among Puerto Rican Injection Drug Users in East Harlem, New York, and Bayamon, Puerto Rico

Drug users have been found to be at high risk of mortality but the mortality experience of Hispanic drug users remains understudied. This study assessed mortality among Puerto Rican injection drug users (IDUs) in New York City (NY), and in Puerto Rico (PR). Study subjects were 637 IDUs from NY and 319 IDUs from PR. Mortality was ascertained using data from the National Death Index. Annual mortality rate of the NY cohort was 1.3 per 100 person years compared to the PR cohort with a rate of 4.8. Compared to the Hispanic population of New York City, the standardized mortality ratio (SMR) of the NY cohort was 4.4. Compared to the population of Puerto Rico, the SMR of the PR cohort was 16.2. The four principal causes of death were: NY—HIV/AIDS (50.0%), drug overdoses (13.3%), cardiovascular conditions (13.3%), and pulmonary conditions (10.0%); PR—HIV/AIDS (37.0%), drug overdoses (24.1%), sepsis (13.0%), and homicide (11.1%). Modeling time to death using Cox proportional hazards regression, the relative risk of mortality of the PR cohort as compared to the NY cohort was 9.2. The other covariates found to be significantly associated with time to death were age, gender, education, social isolation, intoxication with alcohol, and HIV seropositivity. The large disparity in mortality rates found in this study suggests that health disparities research should be expanded to identify intra-group disparities. Furthermore, these results point to an urgent need to reduce excess mortality among IDUs in Puerto Rico.     

Opportunities for outreach: Medicaid participation among children in Ohio

This research seeks to determine individual and household differences between children who enrolled in Medicaid and the Children's Health Insurance Program (CHIP) and children who did not. In addition, the study investigates the specific reasons that families provided for not enrolling their children in Medicaid/CHIP. Data from the 1998 Ohio Family Health Survey were used to determine individual and household differences between children who were enrolled in Medicaid and CHIP and children who were not. Findings show that lower household income, parental unemployment, parental health insurance, and younger (child) age, were associated with greater participation in Medicaid/CHIP among eligible children in Ohio. Children in poorer health and those who resided in counties with higher levels of expenditures on outreach were also more likely to be enrolled. Findings from this study suggest a substantial need to increase awareness about program eligibility and to develop creative outreach strategies aimed at reaching nontraditional Medicaid families.     

Challenges faced by minority children in obtaining dental care

Deaths of children due to neglected dental diseases have put the issue of access to care by minorities at the forefront of dental public health discussions. We evaluated the trends in dental service utilization in relation to racial disparities and other factors using Medicaid enrollment and claims data from 1990 to 1997 for Alabama children 19 years of age and younger (N=512,049). Alabama Medicaid children visited the dentist at a low and declining rate. The number of participating providers gradually declined over time and the racial disparities in service utilization were related to the availability of a local provider. Lower service utilization, however, was not a simple function of race, but a complex interaction of race with age and gender. Identification of these complex interactions and removal of barriers to service utilization in race, age, and gender sub-groups will help the U.S. meet the year 2010 oral health objectives.