Do Enrollees in 'Look-Alike' Medicaid and SCHIP Programs Really Look Alike?

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Georgia presents a unique opportunity to compare the experiences of children enrolled in Medicaid with those enrolled in the State Children's Health Insurance Program (SCHIP), the two federal-state programs that provide health coverage to low-income children. After all, PeachCare for Kids—the state's version of SCHIP—has benefit, provider, and reimbursement structures that are nearly identical to Georgia Medicaid. As this study shows, however, health care utilization and satisfaction differ markedly between the two programs, despite structural similarities.

According to the Health Affairs study "Do Enrollees in 'Look-Alike' Medicaid and SCHIP Programs Really Look Alike?," by Jennifer N. Edwards of The Commonwealth Fund, Janet Bronstein of the University of Alabama, and David B. Rein of Georgia State University, children enrolled in Georgia Medicaid use medical services less often and their parents are generally less satisfied with the care their children receive than those enrolled in PeachCare. Although the mean age (8.7 years) and gender composition (54% male) were found to be similar among Medicaid and PeachCare enrollees, the researchers found that Medicaid children were far more likely to be without a primary care provider (31% Medicaid vs. 19% PeachCare), and their parents reported more problems getting help on the telephone, making appointments, and seeing specialists. Medicaid children were also twice as likely as PeachCare enrollees not to have visited a doctor in the prior six months (26% vs. 13%).

Furthermore, overall satisfaction with care was lower among Medicaid respondents. More Medicaid than PeachCare parents felt, for example, that their physicians did not spend enough time with their children (15% vs. 9%) and that support staffs were unhelpful (13% vs. 8%).

Georgia Medicaid, however, did seem to perform better than PeachCare on certain measures. Medicaid children were found to be less likely to have long waits in the doctor's office, and their parents had less difficulty finding a satisfactory primary care provider. For example, 64 percent of PeachCare enrollees reported waiting more than 15 minutes to see a provider, compared with only 33 percent of Medicaid enrollees.

For their study, the authors surveyed both PeachCare and Medicaid populations using the Consumer Assessment of Health Plans Survey (CAHPS) and held focus groups with each population and with care providers. They then performed analyses that took into account several demographic characteristics, including race, parental education, rural/urban location, special health needs, and child's age. Differences in race and education were found to be associated with different levels of reported access. For example, those reporting their race as black were less likely to have a personal physician, to have visited a doctor in the prior six months, and to have seen a specialist as needed.

Three possible explanations for these differences in use and satisfaction require further study, the authors say. They include:

  • Differences in experiences with insurance and medical care. PeachCare families, who have higher incomes than Medicaid families, are more likely to have had private insurance at some point and are more familiar with accessing primary care physicians.
  • Nonfinancial barriers. Medicaid enrollees are more likely than PeachCare enrollees to have barriers to care, including difficulty finding a doctor, making appointments, or keeping appointments. These problems are not related to the financial structures of Medicaid, but stem from communication or transportation problems. Moreover, Medicaid parents are more likely to have children with complex health problems than PeachCare parents are—and thus are more likely to experience frustrations or disappointments with care.
  • Different responses by physicians to the two programs. Doctors and their staffs report more paperwork, physician assignment, and eligibility verification problems with Medicaid enrollees than PeachCare children. Such difficulties may lead to perceptions of bias against Medicaid among its beneficiaries and may help to explain their lower levels of satisfaction with care.
The authors note that some of the differences may also be attributable to sampling selection bias. For example, the PeachCare enrollees surveyed had been in the program for, at most, 16 months. Since they may have had unmet health needs before being insured, these children would have been more likely to use health services.

Based on their study, the authors believe that policymakers must continue efforts to improve Medicaid enrollees' access to care. For example, steps could be taken to ensure that providers are located in accessible areas, near public transportation routes. Enrollees should be coached on system use, preventive care, and communication techniques. Medicaid and SCHIP administrators may also want to initiate contact, or have their providers initiate contact, with enrollees who have not come forward to access health care on their own. Finally, Medicaid should offer support to providers in managing children with complex needs. This could mean linking providers with community-based services capable of meeting a variety of children's and parents' needs.

Facts and Figures
  • Sixteen percent of parents with Georgia Medicaid-enrolled children reported they "sometimes or never" get an appointment for regular or routine health care as soon as they want, compared with 9 percent of PeachCare (SCHIP) parents.
  • Among Medicaid respondents, 15 percent reported they had a "big problem" getting their child a referral to a specialist, but only 4 percent of PeachCare enrollees reported the same.
  • When asked if their child had seen a specialist when recommended by their doctor in the previous six months, 29 percent of parents with Medicaid-enrolled children answered "no," versus 13 percent of parents with PeachCare-enrolled children.
  • PeachCare parents were twice as likely as Medicaid parents (8% vs. 4%) to report that it was a "big problem" getting a personal doctor or nurse with whom they were happy.

Publication Details

Publication Date:
May 1, 2002
Authors:
Jennifer N. Edwards, Janet Bronstein and David B. Rein
Citation:

"Do Enrollees in 'Look-Alike' Medicaid and SCHIP Programs Really Look Alike?," Jennifer N. Edwards, Janet Bronstein, and David B. Rein, Health Affairs 21, 3 (May 2002): 240–248