Impact of Medicaid Policy on the Oral Health of Publicly Insured Children

Objective Fluoride varnish (FV) applications among non-dentist primary care providers has increased due to state Medicaid policies. In this study we examine the impact of FV policies on the oral health of publicly insured children aged 2–6 years old. Methods Using three waves of the National Survey of Children’s Health (2003, 2007, 2011/12), we used a logistic regression model with state and year fixed effects, adjusting for relevant child characteristics, to examine the association between years since a state implemented a FV policy and the odds of a publicly insured child having very good or excellent teeth. We compared children with public insurance in states with FV policies to children with public insurance in states without FV policies, controlling for the same difference among children with private insurance who were unlikely to be affected by Medicaid FV policies. Results Among 68,890 children aged 2–6 years, 38% had public insurance. Compared to privately insured children, publicly insured children had significantly lower odds of having very good or excellent teeth [odds ratio (OR) 0.70, 95% CI 0.62–0.81]. Publicly insured children in states with FV policies implemented for four or more years had significantly greater odds of having very good or excellent teeth (OR 1.28, 95% CI 1.03–1.60) compared to publicly insured children in states without FV policies. Conclusions for Practice State policies supporting non-dental primary care providers application of FV were associated with improvements in oral health for young children with public insurance.

     

Expanding the definition of access: it isn't just about health insurance

Measurement of access to health care services is often limited to such variables as having health insurance or a usual source of care. We argue for an expanded definition of access measuring whether providers accept a particular form of insurance (overall accessibility), ease of contacting providers for appointments (contact accessibility), length of time it takes to get an appointment (appointment accessibility), and proximity of providers to patients (geographic accessibility). Interviewers posing as Medicaid beneficiaries telephoned providers in Florida's Medicaid primary care case management program, to determine whether the provider was accepting new patients, had weekend or evening hours, and how long it would take to get an appointment. Approximately 87% were accepting new patients, but only 68% were accepting new Medicaid patients. The survey also showed that beneficiaries may encounter difficulty in reaching physicians and making appointments: 22% of all calls were not answered on the first attempt and over two-thirds of providers had no weekend or evening hours.     

Healthcare Providers’ Satisfaction with a State Children’s Health Insurance Program (SCHIP)

Purpose This study’s purpose was to understand how experiences with and perceptions of the health care plan characteristics influence provider satisfaction with a State Children’s Health Insurance Program (SCHIP). Methods Physicians and other health care providers participating in one program (ALL Kids) were mailed a survey (n = 500). Pediatricians were the most likely to return the survey. We used frequencies, chi-square and logistic regression analysis to explore relationships. Results The odds of being less satisfied with the program among providers who perceived that reimbursement in the ALL Kids program was less compared to private insurance were almost 7 times (OR = 6.81; 95% CI = (1.88–24.73)) greater than for those who perceived that reimbursement was more or the same in ALL Kids. Likewise, respondents who perceived that All Kids families were less likely than families with private insurance to return for follow-up visits were less satisfied with ALL Kids (OR = 17.42; 95% CI = (1.85–164.70)). Conclusions The stigma of SCHIP may be less than that often associated with Medicaid; however, this investigation should be considered with others that have identified barriers for provider’s participation. This study indicates that provider satisfaction is related to their perceptions of SCHIP policies and families, though it does not tell us what factors might contribute to this perception, such as, previous experience with public insurance (Medicaid) and publicly insured patients. Increasing reimbursement rates may not address perceptions that affect provider views of publicly-supported health plans and the participating families.     

False hope: effects of social class and health policy on oral health inequalities for migrant farmworker families

Few studies have engaged issues of social class and access related to dental health care policy from an ethnographic perspective. The state of Florida in the US has one of the poorest records in the nation for providing dental care for low-income children, falling especially short for Medicaid-enrolled children. In this paper, we discuss unmet dental health needs of children in migrant farmworker families. Although one of the most marginalized populations, most are eligible for Medicaid and are thus covered for dental services. However, serious disparities have been linked to the lack of access through the public insurance system. This study was informed by participant observation at dental clinics and a Migrant Head Start Center and interviews with dental health providers (n = 19) and migrant farmworker parents (n = 48) during 2009. Our results indicate that some typical factors associated with poor oral health outcomes, such as low dental health literacy, may not apply disproportionately to this population. Instead, we argue that structural features and ineffective policies contribute to oral health care disparities. Dental Medicaid programs are chronically underfunded, resulting in low reimbursement rates, low provider participation, and a severe distribution shortage of dentists within poor communities. We characterize the situation for families in Florida as one of “false hope” because of the promise of services with neither adequate resources nor the urgency to provide them. The resulting system of charity care, which leads dentists to provide pro bono care instead of accepting Medicaid, serves to only further persistent inequalities. We provide several recommendations, including migrant-specific efforts such as programs for sealants and new mothers; improvements to the current system by removing obstacles for dentists to treat low-income children; and innovative models to provide comprehensive care and increase the number of providers.     

Billing and payment of commercial and Medicaid health plan adult vaccination claims in Michigan since the Affordable Care Act

BackgroundProvider concern regarding insurance non-payment for vaccines is a common barrier to provision of adult immunizations. We examined current adult vaccination billing and payment associated with two managed care populations to identify reasons for non-payment of immunization insurance claims.MethodsWe assessed administrative data from 2014 to 2015 from Blue Care Network of Michigan, a nonprofit health maintenance organization, and Blue Cross Complete of Michigan, a Medicaid managed care plan, to determine rates of and reasons for non-payment of adult vaccination claims across patient-care settings, insurance plans, and vaccine types. We compared commercial and Medicaid payment rates to Medicare payment rates and examined patient cost sharing.ResultsPharmacy-submitted claims for adult vaccine doses were almost always paid (commercial 98.5%; Medicaid 100%). As the physician office accounted for the clear majority (79% commercial; 69% Medicaid) of medical (non-pharmacy) vaccination services, we limited further analyses of both commercial and Medicaid medical claims to the physician office setting. In the physician office setting, rates of payment were high with commercial rates of payment (97.9%) greater than Medicaid rates (91.6%). Reasons for non-payment varied, but generally related to the complexity of adult vaccine recommendations (patient diagnosis does not match recommendations) or insurance coverage (complex contracts, multiple insurance payers). Vaccine administration services were also generally paid. Commercial health plan payments were greater for both vaccine dose and vaccine administration than Medicare payments; Medicaid paid a higher amount for the vaccine dose, but less for vaccine administration than Medicare. Patients generally had very low (commercial) or no (Medicaid) cost-sharing for vaccination.ConclusionsAdult vaccine dose claims were usually paid. Medicaid generally had higher rates of non-payment than commercial insurance.     

State Policy Environment and Delayed or Forgone Care Among Children with Special Health Care Needs

Objective To evaluate if children with special health care needs (CSHCN) residing in states with more generous public insurance programs were less likely to report delayed or forgone care. Methods We used multilevel modeling to evaluate state policy characteristics after controlling for individual characteristics. We used the 2001 National Survey of CSHCN for individual-level data (N = 33,317) merged with state-level data, which included measures of the state’s public insurance programs (Medicaid eligibility and enrollment, spending on Medicaid, SCHIP and Title V, and income eligibility levels), state poverty level and provider supply (including pediatric primary care and specialty providers). We also included a variable for state waivers for CSHCN requiring institutional level care. Results Delayed or forgone care significantly varied among CSHCN between states, net of individual characteristics. Of all the state characteristics studied, only the Medicaid income eligibility levels influenced the risk of experiencing delayed care. CSHCN living in states with higher income eligibility thresholds or more generous eligibility levels were less likely to experience delayed care (OR 0.89(0.80,0.99); P ≤ 0.05). Conclusions By analyzing child health policy in the context of individual characteristics that may place a child at risk for delayed care, we determined that improving Medicaid eligibility levels improved the process of care for CSHCN.     

Sustainability of school-located influenza vaccination programs in Florida

BackgroundSchool-located influenza vaccination (SLIV) programs are a promising strategy for increasing vaccination coverage among schoolchildren. However, questions of economic sustainability have dampened enthusiasm for this approach in the United States. We evaluated SLIV sustainability of a health department led, county-wide SLIV program in Alachua County, Florida. Based on Alachua's outcome data, we modeled the sustainability of SLIV programs statewide using two different implementation costs and at different vaccination rates, reimbursement amount, and Vaccines for Children (VFC) coverage.MethodsMass vaccination clinics were conducted at 69 Alachua County schools in 2013 using VFC (for Medicaid and uninsured children) and non-VFC vaccines. Claims were processed after each clinic and submitted to insurance providers for reimbursement ($5 Medicaid and $47.04 from private insurers). We collected programmatic expenditures and volunteer hours to calculate fixed and variable costs for two different implementation costs (with or without in-kind costs included). We project program sustainability for Florida using publicly available county-specific student populations and health insurance enrollment data.ResultsApproximately 42% (n = 12,853) of pre-kindergarten – 12th grade students participated in the SLIV program in Alachua. Of the 13,815 doses provided, 58% (8042) were non-VFC vaccine. Total implementation cost was $14.95/dose or $7.93/dose if “in-kind” costs were not included. The program generated a net surplus of $24,221, despite losing $4.68 on every VFC dose provided to Medicaid and uninsured children. With volunteers, 99% of Florida counties would be sustainable at a 50% vaccination rate and average reimbursement amount of $3.25 VFC and $37 non-VFC. Without volunteers, 69% of counties would be sustainable at 50% vaccination rate if all VFC recipients were on Medicaid and its reimbursement increased from $5 to $10 (amount private practices receive).Conclusions and relevanceKey factors that contributed to the sustainability and success of an SLIV program are: targeting privately insured children and reducing administration cost through volunteers. Counties with a high proportion of VFC eligible children may not be sustainable without subsidies at $5 Medicaid reimbursement.     

Payment levels, resource use, and insurance risk of medicaid versus private insured in three states.

Concerns with access and costs in the Medicaid program often lead policy makers to consider alternatives. These include subsidizing poor persons' purchases of health insurance in private markets or integrating Medicaid beneficiaries into commercial managed care systems. As policy makers consider such alternatives, a persistent question is, apart from the disabled within Medicaid, do younger Medicaid enrollees represent a different insurance risk than people of similar age and sex within private insurance pools? We use 1994 data from Georgia, Mississippi, and California to assess relative payment levels, resource use/costs, and risk-adjusted utilization of fee-for-service (FFS) Medicaid enrollees versus privately insured people. When resources are valued at private prices, the use by Medicaid enrollees represents a higher cost. After risk adjustment, Medicaid enrollee resource use appears higher than expected for the privately insured only for outpatient facility visits in the southern states and for inpatient days by pregnant women in California Medi-Cal. Indeed, we find evidence that Medicaid enrollees are underserved relative to their health needs. Given the higher dollar value of their resource usage, apparently obtained under FFS at discounted provider rates, and the lack of evidence on significant overuse relative to need, their integration into private provider systems appears challenging.     

Prenatal care characteristics and African-American women's satisfaction with care in a managed care organization.

This study examined the characteristics of prenatal care affecting women's satisfaction for two groups of African-American women, those with Medicaid insurance and those with commercial insurance, who sought care through a large managed care organization in the Midwest. African-American pregnant managed care patients (n = 400), regardless of payer status, were more satisfied when their providers spent more time with them and when their providers engaged them by explaining procedures, asking them questions, and answering their questions. Satisfaction was also higher for both Medicaid (n = 125) and commercially insured women (n = 275) when the waiting room was clean and comfortable. The care characteristics most important to an African-American woman's satisfaction with prenatal care do not appear to be dependent on her payer status, nor do they seem to be particularly dependent on the financial arrangements of her care provider. While improvements in health care delivery tend to focus on increasing technical proficiency to improve pregnant women's satisfaction with care, prenatal care providers should focus on improvements in patient-provider communication, as well as features of the prenatal care setting (e.g., cleanliness, waiting times, availability of ancillary services).     

Perceived satisfaction with health services under National Health Insurance Scheme: Clients' perspectives

The study aims to explore the perceived satisfaction of insured clients in financing health services through National Health Insurance in Ghana. A quantitative method was used to recruit 380 respondents, selected by multistage cluster sampling. Data were collected through the administration of questionnaires. More than half, 57.9%, of respondents were males, and the average age was 34 years. Most respondents, 74.3%, were insured. Overall, 53.12% of insured clients were dissatisfied with the services of providers. Factors, such as benefit package of insurance, willingness to pay higher premium, and perceived discrimination were significantly associated with poor satisfaction with health services. The current advocacy for and awareness about the use of health insurance as a prepayment plan should be prioritised in policy initiatives. The benefit package for the insurance should be increased in order to cover all disease conditions that afflict the Ghanaian population.     

Market environment and Medicaid acceptance: What influences the access gap?

The U.S. health care system is undergoing significant changes. Two prominent shifts include millions added to Medicaid and greater integration and consolidation among firms. We empirically assess if these two industry trends may have implications for each other. Using experimentally derived (“secret shopper”) data on primary care physicians' real‐world behavior, we observe their willingness to accept new privately insured and Medicaid patients across 10 states. We combine this measure of patient acceptance with detailed information on physician and commercial insurer market structure and show that insurer and provider concentration are each positively associated with relative improvements in appointment availability for Medicaid patients. The former is consistent with a smaller price discrepancy between commercial and Medicaid patients and suggests a beneficial spillover from greater insurer market power. The findings for physician concentration do not align with a simple price bargaining explanation but do appear driven by physician firms that are not vertically integrated with a health system. These same firms also tend to rely more on nonphysician clinical staff.     

Medicaid provider reimbursement policy for adult immunizations

BackgroundState Medicaid programs establish provider reimbursement policy for adult immunizations based on: costs, private insurance payments, and percentage of Medicare payments for equivalent services. Each program determines provider eligibility, payment amount, and permissible settings for administration. Total reimbursement consists of different combinations of Current Procedural Terminology codes: vaccine, vaccine administration, and visit.ObjectiveDetermine how Medicaid programs in the 50 states and the District of Columbia approach provider reimbursement for adult immunizations.DesignObservational analysis using document review and a survey.Setting and participantsMedicaid administrators in 50 states and the District of Columbia.MeasurementsWhether fee-for-service programs reimburse providers for: vaccines; their administration; and/or office visits when provided to adult enrollees. We assessed whether adult vaccination services are reimbursed when administered by a wide range of providers in a wide range of settings.ResultsMedicaid programs use one of 4 payment methods for adults: (1) a vaccine and an administration code; (2) a vaccine and visit code; (3) a vaccine code; and (4) a vaccine, visit, and administration code.LimitationsStudy results do not reflect any changes related to implementation of national health reform. Nine of fifty one programs did not respond to the survey or declined to participate, limiting the information available to researchers.ConclusionsMedicaid reimbursement policy for adult vaccines impacts provider participation and enrollee access and uptake. While programs have generally increased reimbursement levels since 2003, each program could assess whether current policies reflect the most effective approach to encourage providers to increase vaccination services.     

Association of Provider Scope of Practice With Successful Transition for Youth With Special Health Care Needs

PurposeYouth with special health care needs (YSHCN) encounter unique challenges in the transition from pediatric to adult healthcare. Although discussing transition with healthcare providers can be beneficial, it is unclear whether the providers' scope of practice (child-only vs. lifespan-oriented) drives these discussions. We examined the association between scope of practice and transition-related services.MethodsWe used caregivers' responses in the 2005–2006 National Survey of Children with Special Healthcare Needs. We compared transition outcomes for youth whose providers treated only children, and youth whose providers also treated adults (lifespan-oriented). Individual and household-level demographic factors were applied to logistic regression models.ResultsYouth with lifespan-oriented providers were more likely than youth with child-only providers to have discussed changing health needs in adulthood (52% vs. 43%) and adult health insurance (24% vs. 21%). There was no difference in receiving encouragement toward self-responsibility (79% vs. 78%). These associations persisted after adjusting for demographics.ConclusionsYSHCN are more likely to report having discussed issues related to transition into adult healthcare if their providers treat adults as well as children. However, discussion involving adult health insurance in particular was lacking for all YSHCN.     

Accounting for uncertainty in policy decision making: Improving access to pediatric dental care

ObjectiveTo introduce a statistical inference framework for policy decision making on access to pediatric dental care.Data SourcesSecondary data were collected for the state of Colorado for year 2019.Study DesignThe access model was an optimization model, matching the demand (patients) and supply (providers) of dental care. Sampling distributions of model inputs were specified using hierarchical Bayesian models, with hyperparameters informed by prior information derived from multiple data sources. Simultaneous inference was applied to identify areas for access improvement. The model was applied to make inference on the pediatric dental care in Colorado, accounting for financial access, differentiated into public (Medicaid and CHIP), private (commercial and out‐of‐pocket), and without financial access.Data Collection/Extraction MethodsMultiple data sources informed the access measurement approach including: 2017 American Community Survey, 2019 Colorado Dental Board, and 2019 National Provider Plan and Enumeration System, 2019 InsureKidsNow.gov among others.Principal FindingsThe median access measure (travel distance) was greater than the Colorado access standards in 16.9% and 65.1% of census tracts for children with private financial access and publicly insured, respectively. Accounting for uncertainty (confidence level 99%), these percentages decreased to 14.6% and 25.6%, respectively, with mostly suburban and rural tracts failing to meet the standards. The median disparity for Medicaid and CHIP versus private financial access was greater than 5 miles in 84.5% and 81.6% of census tracts, respectively. Accounting for uncertainty (confidence level 99%), these percentages declined to 19.5% and 10.5%, respectively, with significant disparities around the metropolitan areas.ConclusionsWhile many communities failed to meet access standards, when accounting for uncertainty, most urban ones did not fail. Disparities in spatial access between publicly and privately insured were most acute in urban communities. Medicaid insured experienced higher disparities than CHIP insured; those differences were not identified when not accounting for uncertainty.     

Value for the money spent? Exploring the relationship between expenditures, insurance adequacy, and access to care for publicly insured children

This study examines the relationship between total state Medicaid spending per child and measures of insurance adequacy and access to care for publicly insured children. Using the 2007 National Survey of Children's Health, seven measures of insurance adequacy and health care access were examined for publicly insured children (n = 19,715). Aggregate state-level measures were constructed, adjusting for differences in demographic, health status, and household characteristics. Per member per month (PMPM) state Medicaid spending on children ages 0-17 was calculated from capitated, fee-for-service, and administrative expenses. Adjusted measures were compared with PMPM state Medicaid spending in scatter plots, and multilevel logistic regression models tested how well state-level expenditures predicted individual adequacy and access measures. Medicaid spending PMPM was a significant predictor of both insurance adequacy and receipt of mental health services. An increase of $50 PMPM was associated with a 6-7 % increase in the likelihood that insurance would always cover needed services and allow access to providers (p = 0.04) and a 19 % increase in the likelihood of receiving mental health services (p < 0.01). For the remaining four measures, PMPM was a consistent (though not statistically significant) positive predictor. States with higher total spending per child appear to assure better access to care for Medicaid children. The policies or incentives used by the few states that get the greatest value--lower-than-median spending and higher-than-median adequacy and access--should be examined for potential best practices that other states could adapt to improve value for their Medicaid spending.     

Cherry Picking in the ‘Aina: Inequalities of Access to Dermatologic Care in Hawai‘i

There is evidence that people who are insured by Medicaid have difficulty accessing health care from private providers. This study documents access to dermatology care for a hypothetical patient insured by Medicaid in the State of Hawai‘i. Posing as young Medicaid patient with a changing mole, we called all dermatologists listed on the American Academy of Dermatology website and requested an appointment to be seen. Only 23% of dermatologists contacted accept all Medicaid plans and an additional 12% accept some. Thus 65% of dermatologists called do not provide specialist care to Hawai‘i''s Medicaid population.     

Do expansions in adolescent access to public insurance affect the decisions of substance use disorder treatment providers?

We apply a mixed-payer economy model to study the effects of changes in the generosity of children’s public health insurance programs – measured by Medicaid and Children’s Health Insurance Program income thresholds – on substance use disorder (SUD) treatment provider behavior. Using government data on specialty SUD treatment providers over the period 1997–2011 combined with a two-way fixed-effects model and local event study, we show that increases in the generosity of children’s public health insurance induce providers to participate in some, but not all, public markets. Our effects appear to be driven by non-profit and government providers. Non-profit providers also appear to increase treatment quantity slightly in response to coverage expansions.     

Enrolling and Retaining Uninsured and Underinsured Populations in Public Health Insurance Through a Service Integration Model in New York City

Innovative strategies to identify uninsured and underinsured populations are critical to successful enrollment and retention in public health insurance. The New York City Department of Health and Mental Hygiene’s Office of Health Insurance Services has partnered with the department’s Early Intervention Program to implement a Service Integration Model to enroll special needs children, aged 0 to 3 years, into public health insurance. This model uses data from program databases and staff from children’s programs to proactively identify uninsured and underinsured children and facilitate their enrollment into public health insurance. The model overcomes enrollment barriers by using consumer-friendly enrollment materials and one-on-one assistance, and shows the benefits of a comprehensive and collaborative approach to assisting families with enrollment into public health insurance.

KEY FINDINGS

■ Partnerships across government programs and agencies offer opportunities to enroll hard-to-reach populations into public health insurance.■ The Office of Health Insurance Services Service Integration Model has 3 key components allowing for comprehensive and continuous coverage for children with special health care needs: integration of program messages within the Early Intervention Program, data matching with child program data (Early Intervention data, Medicaid data), and incorporation of program staff (Office of Health Insurance Services child benefit advisors) to work directly with parents.■ The combination of access to child program data to identify children and one-on-one assistance to complete public health insurance applications has successfully assisted more than 5000 families in the New York City Early Intervention Program.IN NEW YORK STATE, AN estimated 12.7% of children have special health care needs.1 According to McPherson et al., children with special health care needs are defined as

those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.2 ^(p.138)

The 2005–2006 National Survey of Children With Special Health Care Needs found that 38% of families with special needs children had inadequate health insurance coverage.1 Data indicate that 16% of children with special health care needs did not receive any health care services in the past year; 45% of uninsured children with special health care needs needed at least 1 service not received, compared with 22% of publicly insured children, 19% of children with dual coverage (public and private), and 11% of privately insured children. Services not received included dental care, mental health care, therapies, and specialty care.In New York City, almost 40 000 children per year with a diagnosed developmental delay or disability receive services through the Early Intervention Program—a federal entitlement program for children aged 0 to 3 years. In New York City, the Early Intervention Program is administered through the New York City Department of Health and Mental Hygiene (DOHMH). Programs for children with special health care needs, such as the National Early Intervention Program, have been created to ensure that infants and children with developmental disabilities or delays receive needed services. To be eligible for services, children must be younger than 3 years and have a confirmed disability or established developmental delay, as defined by the state, in 1 or more of the following areas of development: physical, cognitive, communication, social-emotional, and adaptive.3 These children receive services free of charge for developmental disabilities or delays. The Early Intervention Program bills the child’s health insurance if the program is aware of the health insurance status of the child, including Medicaid and private or employer-based insurance. Parents are not responsible for paying for any services received through the Early Intervention Program. However, the Early Intervention Program does not cover services for routine medical care or specialized medical services (non-developmental disabilities or delays).The Office of Health Insurance Services at the New York City DOHMH was created to expand the city’s health insurance enrollment capacity, maximize client choice regarding health plan and provider selection, and promote health care use and preventive health behaviors. Since 2000, the Office of Health Insurance Services has been a New York State–approved facilitated enrollment lead agency in New York City. The New York State Department of Health–facilitated enrollment program provides funding, through a Request for Application process, to community-based organizations and local entities to provide eligibility screening and application assistance services to New York State residents applying for public health insurance.In 2009, the Office of Health Insurance Services assisted more than 10 000 applicants throughout New York City with a 97% enrollment success rate. The Office of Health Insurance Services maintains a presence at 9 New York City DOHMH centers and serves clients throughout the 5 boroughs, from all racial and ethnic backgrounds and with limited English proficiency.The challenge of ensuring that children with special health care needs receive comprehensive and continuous health insurance coverage requires innovative strategies. Although New York State has made considerable progress in reducing barriers to enrollment in public health insurance for adults and children, challenges remain. To maximize comprehensive insurance coverage for children with special health care needs, a Service Integration Model was formed between the Office of Health Insurance Services and the Early Intervention Program at the New York City DOHMH.

INCLUSION OF INFORMATION ON SERVICES PROVIDED BY THE OFFICE OF HEALTH INSURANCE SERVICES TO THE EARLY INTERVENTION PROGRAM

Information about services provided by Office of Health Insurance Services included in Early Intervention Program trainings and print materials“Early Intervention Welcome Letter” to parents“NYC Early Intervention Program Policy and Procedure Manual” for Early Intervention Program provider agenciesOffice of Health Insurance Services brochure and poster for Early Intervention Program provider agenciesLetter to Early Intervention Program providersData MatchingEarly Intervention Program dataNew York State Medicaid dataCensus dataIncorporation of Office of Health Insurance Services Staff to Work Directly With Parents of Children in Early Intervention ProgramOne-on-one in-person or telephone assistanceAvailable in multiple languagesAvailable at hours and locations convenient to parentsEducate families on public health insurance productsHelp them apply for coverage     

Smile Alabama! Initiative: Interim Results From a Program to Increase Children's Access to Dental Care

ABSTRACT: Alabama faced an oral health crisis, with decreasing dental provider participation and increasing enrollment of Medicaid-eligible children. In response, the Smile ALabama! initiative was designed to improve oral health care services for Medicaid-eligible children by increasing the number of participating dentists by 15% and the number of children receiving dental care annually by 5% by January 31, 2004. The initiative is composed of 4 specific components: claims processing, dental reimbursement, provider education and recruitment, and recipient education. Specific interventions were implemented for each component. From fiscal year 1999 to fiscal year 2002, enrollment of targeted Medicaid children increased 32.7%. During this same period, the number of participating dental providers in the Alabama Medicaid dental program increased by 127 providers, a 38.7% increase. The number of children receiving dental services increased from 82 600 in fiscal year 2999 to 130 208 in fiscal year 2002, a 57.1% total increase, with a 4.8% increase in the annual dental visit rate. The experience suggests that access fo oral health care services can be improved through a multidimensional, strategically planned dental outreach initiative in spite of dramatic increases in Medicaid enrollment .     

Children’s Insurance Coverage and Crowd-Out Through the Recession: Lessons From Ohio

Objectives. We estimated changes in children’s insurance status (publicly insured, privately insured, or uninsured) and crowd-out rates during the 2007 to 2009 US recession in Ohio.Methods. We conducted an estimate of insurance coverage from statewide, randomized telephone surveys in 2004, 2008, 2010, and 2012. We estimated crowd-out by using regression discontinuity.Results. From 2004 to 2012, private insurance rates dropped from 67% to 55% and public rates grew from 28% to 40%, with no change in the uninsured rate for children. Despite a 12.0% decline in private coverage and a corresponding 12.6% increase in public coverage, we found no evidence that crowd-out increased during this period.Conclusions. Children, particularly those with household incomes lower than 400% of the federal poverty level, were enrolled increasingly in public insurance rather than private coverage. Near the Medicaid eligibility threshold, this is not from an increase in crowd-out. An alternative explanation for the increase in public coverage would be the decline in incomes for households with children.During the economic recession of 2007 to 2009, 8 million Americans lost employer-sponsored health insurance.1 During this same period, the national rate of uninsurance among adults increased by 15% while the rate for children decreased by 7%, as children increasingly moved from private insurance to public programs including Medicaid and the Children’s Health Insurance Program (CHIP).1 With spending for Medicaid accounting for almost 20% of state budgets,2 increases in Medicaid enrollment raise concerns for many state governments. A key debate among state legislators is whether these changes represent Medicaid fulfilling its planned role as a safety net or whether these increases represent Medicaid replacing or crowding-out private insurance coverage.Crowd-out refers to individuals who are insured by a public program but who otherwise would have private insurance if the public program did not exist. The archetype of crowd-out is when privately insured individuals gain eligibility for Medicaid and drop their private coverage to enroll in the public plan. This scenario is often referred to as public–private “substitution” in the literature.3 It should be noted that individuals who can no longer afford private individual insurance or who lose access to, or cannot afford their employer-sponsored plan, are excluded from crowd-out estimates. For example, a child whose parent has private insurance but cannot afford to include the child on the plan4 would not be considered to be crowded out. The second type of crowd-out, which we refer to as continuation crowd-out, occurs when an individual on a public program becomes eligible to enroll in an employer-sponsored private plan, but chooses to remain on public coverage. This scenario could occur when an unemployed parent begins a new job that offers an affordable, employer-sponsored plan, but the parent decides to keep their child enrolled in Medicaid instead of the newly available private option.The published literature primarily focuses on estimates of crowd-out based on increased enrollment following the expansion of eligibility, such as a state increasing Medicaid income eligibility limits. These estimates vary widely, ranging from high estimates of 50% (i.e., half of individuals gaining Medicaid coverage through an expansion would otherwise have private insurance) to other authors finding near zero crowd-out.5–7 Some of this variability is driven by the sensitivity of the econometric models used8 and some may be attributable to the actual crowd-out that occurred with different expansions of eligibility in different states.5 A smaller literature directly measures substitution from survey data, finding low levels of this type of crowd-out.9,10 From a legislative perspective, these crowd-out estimates reveal the budgetary cost of Medicaid expansions. For the average state in 2012, insuring a child through Medicaid cost $2700 per year.11 At a 50% crowd-out rate, a state would need to budget $5400 to reduce the number of uninsured by 1 child. The $5400 would include coverage for the previously uninsured child and for a second child who previously had private insurance (1 uninsured child and 1 case of crowd-out).The existing crowd-out literature implicitly assumes that crowd-out estimates are stable over time. The econometric approaches used in most studies require a change in Medicaid eligibility to estimate crowd-out, producing a single, national estimate for the policy change.5,12 Absent a more recent change, policymakers assume that crowd-out rates do not change with time because those estimates are not time dependent. This implicit assumption, though, is likely invalid. Crowd-out indicates the use of public insurance while private coverage is still available; the reasons for that are likely dependent on the current cost and expected future cost of insurance, the suitability of access provided by the types of coverage, and noneconomic factors such as the stigma associated with public coverage.13Each of these factors can change over time. Concern about the future cost of insurance during the recession may have been particularly important, as parents may have had strong concerns about retaining their employment or concerns that their employer would stop offering employer-sponsored health insurance. Between January 2007 and January 2010, Ohio’s unemployment rate almost doubled from 5.4% to 10.6%.14 This increase in the unemployment rate may have raised parents’ concerns about future access to health care for their children. If these concerns led to increased enrollment in public insurance, then crowd-out would increase. Previous work has not estimated state-level crowd-out levels over time. We evaluated how many children in Ohio moved from private health insurance to public health insurance and the degree to which those children were crowded out between 2004 and 2012. We estimated total crowd-out (substitution plus continuation) over time to see whether crowd-out levels changed during the recession in Ohio.