Researchers examine poor children's access to public insurance coverage and health care

Prior to the 1996 passage of the State Children's Health Insurance Program (SCHIP), nearly 5 million uninsured children were Medicaid-eligible but not enrolled. A recent national survey found that individual uncertainty about Medicaid eligibility, Medicaid's link to welfare, the complexity of the enrollment process, and language issues are major barriers to people becoming enrolled in Medicaid. Even after insurance has been obtained, covered children can experience difficulties accessing health care.

A new study supported by the Agency for Healthcare Research and Quality shows that limited English-language proficiency is a major barrier to becoming enrolled in State Medicaid programs. A second study, part of the Child Health Insurance Research Initiative (CHIRI™) sponsored by AHRQ, the David and Lucile Packard Foundation, and the Health Resources Services Administration, reveals that in Georgia, children in Medicaid-insured families have a more difficult time gaining access to care than children enrolled in SCHIP. Both studies are described here.

Feinberg, E., Swartz, K., Zaslavsky, A.M., and others. (2002, March). "Language proficiency and the enrollment of Medicaid-eligible children in publicly funded health insurance programs." (AHRQ grant HS10207). Maternal and Child Health Journal 6(1), pp. 5-18.

With the increasing diversity of the American population, a growing number of people living in the United States are not proficient in the English language. These families, regardless of marital and employment status, have more difficulty finding out about and enrolling in State Medicaid health insurance programs, according to this study. The authors recommend that screening and enrollment at medical sites remain an integral part of outreach efforts targeted at linguistically isolated families. They surveyed 1,055 parents of Medicaid-eligible children who were not enrolled in the Massachusetts State Medicaid program but instead were enrolled in the Massachusetts Children Medical Security Plan, a State insurance program with a more limited benefit package.

Respondents were asked how they learned about and enrolled their children in the State Medicaid program and perceived barriers to enrollment. Almost one-third of the families surveyed did not speak English in their home. They were less aware of the State Medicaid program than English-proficient families and were more likely to hear about the Medicaid program from medical providers (70 vs. 47 percent). After controlling for other demographic factors, these families with limited English proficiency were three times more likely than English-proficient families to receive assistance with enrollment. They also were more likely to receive this help from staff at medical sites rather than the toll-free telephone information line.

Families who were not proficient in English were more likely than English-proficient families to identify barriers to Medicaid enrollment related to "know-how." Compared with English-proficient families, they were more likely not to know if their family was eligible for coverage under Medicaid (70 vs. 60 percent), not to know how to sign up for Medicaid (43 vs. 26 percent), and to find the enrollment forms too difficult (18 vs. 8 percent). These differences in access to Medicaid enrollment persisted, even after controlling for marital status, family composition, place of residence, length of enrollment, and employment status.

Edwards, J.N., Bronstein, J., and Rein, D.B. (2002, May). "Do enrollees in 'look-alike' Medicaid and SCHIP programs really look alike?" (AHRQ grant HS10435). Health Affairs 21(3), pp. 240-248.

Poor children insured by Georgia's Medicaid program had worse access to health care than children enrolled in Georgia's SCHIP, PeachCare for Kids, despite the fact that the two insurance programs have nearly identical rules and providers. Medicaid survey respondents reported more problems with access to primary, specialty, and urgent care than those enrolled in PeachCare. Parents of Medicaid children were much more likely to report being without a primary care provider, despite being assigned one. They reported more difficulties getting help on the telephone, making appointments, getting specialty referrals, seeing specialists, and getting urgent care as soon as they wanted it. More of their children than PeachCare children had not had an office visit in the previous 6 months. These results persisted, even after adjustment for race, education, and other factors.

Medicaid respondents also felt that their doctors did not spend enough time with them and that office staff were less helpful compared with PeachCare enrollees. Not surprisingly, their overall satisfaction with doctors was lower than PeachCare enrollees. Results from focus groups with parents agreed with these findings. Medicaid parents, as well as PeachCare parents with prior Medicaid experience, said that they felt a stigma when on Medicaid. They believed that office staff treated them differently and that they had to wait longer for appointments.

The researchers offered three possible explanations for these differences. Medicaid families may be less familiar with and supportive of systems requiring use of an assigned primary care doctor, the families may face more nonprogram barriers to using care (for example, transportation or childcare problems), and physicians may have different responses to the two programs. These findings, based on responses to the Consumer Assessment of Health Plans Study (CAHPS®) Medicaid managed care child survey completed by 720 PeachCare enrollees and 2,490 Medicaid enrollees in 2000, were corroborated by focus groups with physicians and parents.

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