DC Child Accident & Safety Blog

Children on the public Medicaid program who need to see a doctor for a serious but non-emergency health issue are shunned by many pediatricians' offices when their parents try to get appointments, according to a new study.

Two out of three get rejected entirely, and the average wait time for those who do get an appointment is three weeks longer than kids on private insurance.

This study gives scientific credence to the common hunch that children with public health insurance receive lesser care than those with private insurance.

According to an auditing study published in the New England Journal of Medicine this month, expanded eligibility for Medicaid and the Children's Health Insurance Program (CHIP) has not been accompanied by easier access.

"There's never been a study this comprehensive or this rigorous that actually measured access to specialty care, let alone children's access," said Karin V. Rhodes, M.D., an author of the study and director of emergency care policy research in the department of emergency medicine at the University of Pennsylvania.

Researchers telephoned clinics for medical appointments pretending to be the parent of a child with an urgent problem that wasn't an emergency. Problems included diabetes, seizures, asthma and broken bones. If asked, they said a primary care doctor or emergency department had referred them.

Sixty-six percent of the Medicaid-CHIP callers were denied an appointment versus 11% of privately insured callers.

Among 89 clinics that accepted both types of insurance, the average wait time for Medicaid-CHIP enrollees was 22 days longer than that for privately insured children.

Researchers attributed the disparity to low and delayed Medicaid fees that also were encumbered by red tape. The study, said the New York Times, is one of only a few efforts to measure access to health care among people with Medicaid.

Medicaid supplies coverage to one in five Americans at some point in a given year, and publicly insured patients are poised to find themselves wedged even deeper between the rock of financially strapped states and the hard place of diminishing coverage. As described in another New York Times story, the Obama administration's infusion of billions of dollars into Medicaid during the depths of the recession is expiring, and benefits are being cut for millions of recipients.

In one example from the study, Medicaid paid $99.86 for an office visit for a problem of "moderate severity," compared with $160 from a private insurer. Several doctors said their practices were threatened by accepting too many Medicaid patients, Rhodes reported; specialists said they would be willing to treat more Medicaid patients but the academic medical centers with which they were affiliated pressed them to see more patients with private insurance.

As health-care experts widely acknowledge, the blowback of diminishing resources will be felt elsewhere within the health-care system. Patients whose doctors refuse to accept lower Medicaid payments often turn to hospital emergency rooms for routine as well as urgent care. Other health-care providers--individuals and institutions--often try to recover lost Medicaid revenue with increased charges to privately insured patients.

Those children who get their care through emergency rooms often are sicker than kids with more ready access to the health care system, because their harried parents wait until the child is really, really sick to go to the ER. Their care winds up being more expensive than if the illness was nipped in the bud with earlier care. Thus a vicious cycle is born.

Meantime, the harsh and impossible reality for poor families is: Don't let your kid get sick.

The Journal of the American Medical Association reports that more than 2 million children without health insurance have parents with health insurance that covers the working parent only.

Why is this? Because, the researchers say, the parents cannot afford the large payments needed to insure the child.

“I think there’s been a myth that all uninsured children have uninsured parents, and so if we cover the parents we can cover the kids,” said Dr. Jennifer DeVoe of Oregon Health & Science University, who led a study, in an interview. “In most cases, the parents have insurance through work at a reduced rate or no cost, but adding their family is unaffordable.”

The article points out that most of these children are from single-parent families, Hispanic families, and live in the South or the West. Many of them may qualify for some form of public assistance but their parents are unaware of it.

The abstract of the JAMA article can be found here. If you follow it, you will see that 3% of all American children are uninsured with at least one insured parent. This kind of situation is frequently found in low-income households, but middle-class income is also a predictor of being in this position. Even middle-class families aren't immune to this tragic problem.

There is a racial gap in health care and health insurance in the U.S. For instance, we can look at this specific case of black and Hispanic children in Massachusetts going without dental care.

From the article:

The report found that one in four children in the state start school with dental disease. Twenty-four percent of Hispanics and 23% of black children who are kindergarten age have untreated cavities, rates nearly twice that of whites, according to the report.

In addition, two-thirds of third grade children in low-income families have tooth decay, about two times the rate of tooth decay among children in families with higher incomes, the report found.

Dental problems are often thought of as frivolous or less than urgent. That view is erroneous. In addition to the severe pain that comes with many dental problems, they can also lead to infections and other serious and even life-threatening conditions. For instance, see the case of 12-year-old Diamante Driver from Prince George's County, Maryland who died from an infection of an abscessed tooth. This death could have been prevented with routine dental care.

Seventeen-year-old Nataline Sarkisyan was suffering from leukemia, and developed complications. Because of this, she needed a liver transplant. Or so her doctors said. But that was not good enough for her insurance company, CIGNA Healthcare.

CIGNA decided that the transplant was unnecessary. Their reasoning? There was not enough evidence that the transplant would help Nataline--despite the fact that the doctors treating her judged that it would.

Curiously enough, CIGNA bureaucrats changed their minds about the efficacy of the transplant after a large protest outside their offices in Glendale, CA. If CIGNA truly believed that the transplant was useless on the merits of the medical evidence, one wonders why the protests would have changed their minds. No amount of protesters can alter the facts, after all. It is almost enough to make you think that their decision to deny Nataline the transplant was based on something other than medical evidence, and that they reversed their decision because the bad publicity made it convenient for them to do so.

Sadly, the reversal came too late for Nataline, who died on Thursday December 20th.

Significantly, there is no hint that CIGNA will change their general policy about such situations. In a statement, they made it clear that their reversal of the denial in this case was an aberration:

CIGNA HealthCare has decided to make an exception in this rare and unusual case and we will provide coverage should she proceed with the requested liver transplant

So the next CIGNA-insured family with a child who needs a transplant must hope that they, too, will be able to rally over a hundred protesters to their cause.

As discussed in a previous post "New Federal Guidelines Would Increase Numbers of Uninsured Children", some states have responded to the health insurance crisis by increasing eligibility for SCHIP (the State Children's Health Insurance Plan) and allowing more families above the poverty line to benefit from it.

The federal government has reacted to this by announcing that it will impose new rules on these states--including, most controversially, a one-year waiting period without insurance before a child can be eligible for SCHIP.

However, states are challenging the federal government's impositions. For instance, Governor Christine Gregoire of Washington state, Governor Arnold Schwarzenegger of California and Governor Eliot Spitzer of New York have all protested the federal government's actions and have questioned the legality of the new federal rules. The outcome of this battle will be interesting not only for its consequences for public health but also for its potential re-shaping of the boundaries between state and federal power.

The Bush administration is attempting to rein in spending for SCHIP--the State's Children Health Insurance Program. SCHIP provides insurance for those children who do not qualify for Medicare but who are nevertheless unable to afford private insurance.

As the article linked above notes, children in 18 states could be affected and 29,000 children in New Jersey alone could lose insurance thanks to the federal guidelines the Bush administration is pushing.

More about this health insurance program comes from Kevin Freking of the Associated Press. The AP article cites angry objections from state health officials. Of particular concern is the year-long wait mandated in the new guidelines: children would have to be uninsured for a year before qualifying for SCHIP.

USA Today has a story about yet another quirk in the American healthcare system: vaccines that are fully covered by Medicaid.for uninsured kids are out of the reach of kids with some, but not enough, health insurance.

From the article:

"It's ironic that kids who are uninsured are better off," said lead author Grace Lee, a pediatric infectious disease specialist at Harvard Medical School.

An estimated 14% of children are underinsured, Lee and colleagues report. They can pay for vaccines or get them free at federally qualified health centers or rural health clinics if they live near one. "Technically, they have access," Lee says, "but they might have to go 200 miles" to the nearest center.

Of course this means that they do not, in reality, have access because a family that cannot afford to properly insure its children probably cannot take 200 mile trips whenever it pleases.

Lack of vaccines leave these kids vulnerable to diseases such as meningitis. This is clearly a serious public health problem.