Public health insurance programs such as Medicaid and CHIP have successfully improved coverage for low-income children and adults. Evidence remains mixed as to the actual health outcomes achieved through these programs.
As the time draws near for the complete enactment and execution of the Affordable Care Act (ACA), efforts to develop evaluation processes of its intended goals of providing health care to approximately 32 million uninsured Americans and improving the health status of these individuals are being considered. This legislative package has been compared to other ground-breaking health care laws such as the State Children’s Health Insurance Program (CHIP) that expanded health care coverage to children of families whose income was above eligibility for Medicaid but were still unable to afford or obtain private insurance coverage from their employers.
There have been numerous research articles that evaluated the change in health care enrollment, eligibility, and coverage status of children since the passage of CHIP in 1997. The authors of this article completed a synthesis evaluation of selected research studies providing a comprehensive preview of health care changes and improvements that may be expected for uninsured adults who will soon become eligible for publicly funded health insurance (Medicaid) through the ACA in 2014.
The researchers completed an exhaustive literature search for studies that included children ages 1 to 18 years, focused on Medicaid and CHIP expansions, provided quantitative effects, examined selected impact measures (e.g. enrollment, access, and health status), controlled for selection biases and confounding changes, and published in the formal peer-reviewed literature.
Thirty eight out of 231 papers reviewed were included in the final synthesis. Since each study differed in several dimensions, a formal meta-analysis was not feasible. Therefore, box plots were used in order to portray the range and central tendency of effect sizes for each impact measure evaluated for each subsequent expansion of either CHIP or Medicaid.
There was an increase in enrollment in public coverage by a median estimate of 11.1 percent and a decrease of 7.3 percent of uninsured children. There were no significant changes to the decline in private insurance enrollment.
Improvement in access to care based on enrollment expansion was evidenced by an 11.5 percent increase in having a usual source of medical care, a 6.3 percent increase in any medical visits, a 3.0 percent increase for having a preventative visit, and a 12.0 percent decrease in having any unmet medical needs.
Access to dental care also improved. There was a 14.5 percent increase in having a usual source of dental care, a 16 percent increase for any dental visit, and a 9.5 percent decrease in any unmet dental need.
There was limited evidence that Medicaid or CHIP expansions had an impact on actual child health outcomes. Only one of four studies evaluating perceived health status noted improvements as a result of coverage expansion. Studies assessing avoidable hospitalizations were also mixed. Four found improvements after coverage expansions while two failed to show any improvement. Lastly, research assessing mortality changes noted that a 10 percent increase in eligibility reduced child deaths by 3 percent.
The lack of peer-reviewed research focused on Medicaid and CHIP expansions display the need for more evidence-based policy research in order to continue the critical and well-needed evaluations of these programs with unbiased views. These evaluations can help ensure that progressive changes made to these programs will optimize their anticipated results.
Although this synthesis review was unable to show consistently positive improvements in the health status of its pediatric enrollees, the positive improvements in enrollment and access to care with each expansion of eligibility gives some sense of optimism in the belief that the enrollees’ health statuses might be positively affected as well.
It is generally believed that history will repeat itself, and with the improvement of the health care enrollment and access, the Affordable Care Act has a great chance of being an effective vehicle to provide for currently unmet medical needs to a large uninsured adult population.
Tyree Winters, DO