Using Discontinuous Eligibility Rules to Identify the Effects of the Federal Medicaid Expansions on Low Income Children

This paper exploits the discrete nature of the eligibility criteria for two major federal expansions of Medicaid to measure the effects on Medicaid coverage, overall health insurance coverage, and the probability of visiting a doctor. The '100 percent' expansion, effective in 1991, extended Medicaid eligibility to children born after September 30, 1983 in families below the poverty line. We estimate that this law led to about a 10 percentage point rise in Medicaid coverage for children born just after the cutoff date, and a similar or slightly smaller rise in overall health insurance. It also increased the fraction of children in the newly eligible group with a doctor visit in the previous year. The '133 percent' expansion, effective in 1990, extended Medicaid to children under 6 in families with incomes below 133 percent of the poverty line. This law had relatively small effects on Medicaid coverage for children near the eligibility limits, and little or no effect on health insurance coverage.

Medicaid Expansions and The Crowding Out of Private Health Insurance

In this paper, we re-examine the question of crowd out among children. Our primary contribution is the use of longitudinal data. These data allow us to identify several groups of children depending on whether their eligibility for Medicaid was affected by the eligibility expansions, and to investigate whether changes in insurance coverage of children affected by the expansions differed from changes in insurance coverage of children unaffected by the expansions. For example, we directly measure whether children who became eligible for Medicaid due to the expansions decreased their enrollment in private insurance plans faster than children whose eligibility for Medicaid was unaffected by the expansions. Our results suggest that there was relatively little crowd out among children. We estimate that 14.5 percent of the recent increase in Medicaid enrollment came from private insurance.

Public Health Insurance, Program Take-Up, and Child Health

Of the ten million uninsured children in 1996, nearly half were eligible for Medicaid, the public health insurance program for poor families, but not enrolled. In response, policy efforts to improve coverage have shifted to increasing Medicaid take-up among those already eligible rather than expanding eligibility. However, little is known about the reasons poor families fail to use public programs or the consequences of failing to enroll. The latter is of particular relevance to Medicaid given that children are typically enrolled when they become sufficiently sick as to require hospitalization. Using new data on Medicaid outreach, enrollment and child hospitalizations in California, I find that information and administrative costs are important barriers to program enrollment, with the latter particularly true for Hispanic and Asian families. In addition, enrolling children in Medicaid before they get sick promotes the use of preventative care, reduces the need for hospitalization and improves health.

In Search of Dental Care: Two Types of Dentist Shortages Limit Children's Access to Care

Each year in the United States, tens of millions of children, disproportionately low-income, go without seeing a dentist.This lack of access to dental care is a complex problem fueled by a number of factors, with two different dentist shortages compounding the issue: An uneven distribution of dentists nationwide means many areas do not have an adequate supply of these practitioners. As a result, access to care is constrained for people in these communities regardless of income or insurance coverage.The relatively small number of dentists who participate in Medicaid means that many low-income people are not receiving dental care.National standards set by dental and pediatric organizations call for children to visit a dentist every six months.The federal government requires state Medicaid programs to enact their own standards after consulting with these organizations, but new data show that more than 14 million children enrolled in Medicaid did not receive any dental service in 2011.According to the most recent comparison, in 2010, privately insured children were almost 30 percent more likely to receive dental care than those who were publicly insured through Medicaid or other government programs, even though low-income children are almost twice as likely as their wealthier peers to develop cavities.4 In 22 states, fewer than half of Medicaid-enrolled children received dental care in 2011.In 2012, Dr. Louis W. Sullivan, secretary of health and human services under President George H.W. Bush, said, "In a nation obsessed with high-tech medicine, people are not getting preventive care for something as simple as tooth decay." He pointed to the inadequate dental workforce as a driving factor, stating, "The shortage of dental care is going to get only worse."This issue brief examines the lack of access to dental care, especially for low-income children and families, in the United States. It also explores strategies states are employing -- particularly expansion of the dental team by licensing additional types of providers -- to address workforce shortages and better serve low-income children

Medicaid in Small Towns and Rural America: A Lifeline for Children, Families and Communities

Medicaid is a vital source of health coverage nationwide, but the program's role is even more pronounced in small towns and rural areas. Medicaid covers a larger share of nonelderly adults and children in rural and small-town areas than in metropolitan areas; this trend is strongest among children. Demographic factors have an impact on this relationship: rural areas tend to have lower household incomes, lower rates of workforce participation, and higher rates of disability— all factors associated with Medicaid eligibility. In addition, the role of Medicaid has increased in the past few years both in small towns and rural areas and in metropolitan areas, given the implementation of the Affordable Care Act (ACA) and more aggressive efforts to enroll children in Medicaid and the Children's Health Insurance Program (CHIP). Because Medicaid plays such a large role in small towns and rural areas, any changes to the program are more likely to affect the children and families living in small towns and rural communities

Measuring and Improving Health Care Quality for Children in Medicaid and CHIP: A Primer for Child Health Stakeholders

A large body of evidence shows that, compared to low-income uninsured children, Medicaid has been highly successful in providing children with a usual source of care and regular well-child care while significantly reducing unmet or delayed needs for medical care, dental care, and prescription drugs due to costs. Nonetheless, quality improvement centers on the notion that systematic and continuous actions lead to measurable improvement in health care services and health status. To this end, health care quality improvement efforts in Medicaid and the Children's Health Insurance Program (CHIP) have accelerated significantly in the past several years largely due to the CHIP Reauthorization Act of 2009 (CHIPRA) and the Affordable Care Act of 2010 (ACA). In May 2015, the Centers for Medicaid and Medicare Services (CMS) also proposed a major modernization of federal rules regarding Medicaid managed care. If enacted, the regulations will have sweeping implications for state quality strategies that extend to all health care delivery mechanisms, including fee-for-service. Provisions in the new rules call for transparency and for states to engage stakeholders in planning and implementation.Given the acceleration in health care quality improvement and opportunities for stakeholder engagement, this brief is intended as a primer for child health policy and advocacy organizations that want to focus their efforts beyond coverage to ensure that every child enrolled in Medicaid and CHIP receives high quality health care. The goal is to help stakeholders better understand the current state of quality measurement and improvement, specifically as it pertains to children enrolled in Medicaid and CHIP. It covers a brief history of health care quality efforts, explains the basics of quality measurement and improvement, discusses the challenges in data collection and analysis, and describes how quality improvement initiatives work. Importantly, it discusses the key roles that child health policy and advocacy organizations can play in making sure that our public coverage programs for children deliver high quality health care that advances health outcomes and strives for continuous improvement

Maximizing Kids' Enrollment in Medicaid and SCHIP

Reviews the 2006 report "Seven Steps Toward State Success in Covering Children Continuously" and recommends the most effective state strategies for increasing enrollment and retention of children in Medicaid and State Children's Health Insurance Programs

Key Issues in Children's Health Coverage

This brief reviews children's coverage today and examines what is at stake for children's coverage in upcoming debates around funding for the Children's Health Insurance Program (CHIP), repeal and replacement of the Affordable Care Act (ACA), and restructuring of Medicaid financing to a block grant or per capita cap. Following decades of steady progress, largely driven by expansions in Medicaid and CHIP, the children's uninsured rate has reached an all-time low of 5%. Medicaid and CHIP are key sources of coverage for our nation's children, covering nearly four in ten (39%) children overall and over four in ten (44%) children with special health care needs. Medicaid serves as the base of coverage for the nation's low-income children and covered 36.8 million children in fiscal year 2015. CHIP, which had 8.4 million children enrolled in fiscal year 2015, complements Medicaid by covering uninsured children above Medicaid eligibility limits.There is much at stake for children's coverage in upcoming debates. New legislative authority is needed to continue CHIP funding beyond September 30, 2017. In addition, the Administration and Republican leaders in Congress have called for repeal and replacement of the ACA and restructuring of Medicaid financing to a block grant or per capita cap. Loss of CHIP funding, repeal of the ACA, and capping Medicaid financing all have the potential to reverse the coverage gains achieved to date and increase the number of uninsured children. In addition, rollbacks in coverage for parents could contribute to coverage losses among children and increased financial instability among families.Reductions in children's coverage would lead to reduced access to care and other long-term effects for children and increase financial pressure on states and providers. Reductions in children's coverage would result in fewer children accessing neededcare, including preventive services such as well child visits and immunizations. Research also suggests that reductions in children's coverage could have broader long-term negative effects on their health, education, and financial success as adults. In addition, loss of CHIP funding and reductions in federal Medicaid financing would create funding gaps that would increase financial pressure on states and providers

Using Discontinuous Eligibility Rules to Identify the Effects of the Federal Medicaid Expansions on Low Income Children

Despite intensive scrutiny, the effects of Medicaid expansions on the health insurance status of low-income children remain controversial. We re-examine the effects of the two largest federally-mandated expansions which offered Medicaid coverage to low-income children in specific age ranges and birth cohorts. We use a regression discontinuity approach, comparing Medicaid enrollment, private insurance coverage, and overall insurance coverage on either side of the age limits of the laws. We conclude that the modest impacts of the expansions on health insurance coverage arose because of very low takeup rates of the newly available coverage, rather than from crowd-out of private insurance coverage.

Differences in Utilization of Dental Procedures by Children Enrolled in Wisconsin Medicaid And Delta Dental Insurance Plans

Background Few studies have directly compared dental procedures provided in public and private insurance plans for enrollees living in dental health professional shortage areas (DHPSAs). We examined the rates for the different types of dental procedures received by 0–18-year-old children living in DHPSAs and non-DHPSAs who were enrolled in Medicaid and those enrolled under Delta Dental of Wisconsin (DDW) for years 2002 to 2008. Methods Medicaid and DDW dental claims data for 2002 to 2008 was analyzed. Enrollees were divided into DDW-DHPSA and non-DHPSA and Medicaid-DHPSA and non-DHPSA groups. Descriptive and multivariable analyses using over-dispersed Poisson regression were performed to examine the effect of living in DHPSAs and insurance type in relation to the number of procedures received. Results Approximately 49 and 65 percent of children living in non-DHPSAs that were enrolled in Medicaid and DDW received at least one preventive dental procedure annually, respectively. Children in DDW non-DHPSA group had 1.79 times as many preventive, 0.27 times fewer complex restorative and 0.51 times fewer endodontic procedures respectively, compared to those in Medicaid non-DHPSA group. Children enrolled in DDW-DHPSA group had 1.53 times as many preventive and 0.25 times fewer complex restorative procedures, compared to children in Medicaid-DHPSA group. Conclusions DDW enrollees had significantly higher utilization rates for preventive procedures than children in Medicaid. There were significant differences across Medicaid and DDW between non-DHPSA and DHPSA for most dental procedures received by enrollees