Examining the effects of cost sharing on utilization and disparities in children's medicaid and CHIP


Dr. Paula Song, College of Public Health (no longer with OSU)
Rank at time of award: Assistant Professor


Medicaid and the Children's Health Insurance Program (CHIP) serve as the primary insurer for low­ income, minority children in the United States (Kaiser Commission on Medicaid and the Uninsured 2009).    Over the past decade, these public programs have significantly expanded and increased health insurance and access to care for children in low income families.  However, children enrolled in Medicaid and CHIP programs are disproportionately  represented by minorities.  Roughly 2 out of every 5 African-American  and Hispanic children are enrolled in Medicaid or CHIP, compared to 1 out of every 5 white children (Lillie-Blanton, Thomas, DiJulio et al. 2009).  Public health insurance expansions  have improved the access to care, quality of care, health outcomes of children in the US (Szilagy, Klein, Shone, Zwanger, McInerny 2004; Szilagy, Klein, Shone, Zwanger, Bajorska, Yoos 2006).  In addition, previous research demonstrates that having health insurance raises levels of access to health care among all racial and ethnic groups (Lillie-Blanton, Thomas, DiJulio et al. 2009).  Despite this, having health insurance alone does not appear to reduce or narrow racial and ethnic disparities among children. Black and Hispanic children who are insured are approximately twice as likely to lack a usual source of care compared to insured white children. Similarly, insured black and Hispanic children are also significantly less likely to have had an ambulatory office visit compared to insured white children (Lillie-Blanton, Thomas, DiJulio et al. 2009). 
Public insurance programs like CHIP and Medicaid reduce cost as a barrier to accessing care, however, many states are resurrecting this barrier to access by imposing cost sharing techniques in attempt to control health care costs.  For example, many states have increased cost sharing for non-emergent emergency department (ED) visits. This trend of states imposing or increasing cost sharing for CHIP and Medicaid enrollees is likely to increase with the recent passage of the health care reform bill and its planned expansion of Medicaid programs and removal of cost sharing for preventive visits. These increases in out-of-pocket costs can have serious consequences for child and family well-being, as many families will face higher health spending burdens even with minimal cost sharing for their publicly insured children (Selden, Kenney, Pantell and Ruhter  2009).  In addition, shifting more costs to Medicaid and CHIP enrollees will disproportionately  increase the burden on minority children, who are already at greater risk of having lower access to care.
The objectives of this study are to evaluate the effects of cost sharing for children enrolled in public health programs on patterns of use of health services and to investigate whether minorities are particularly affected given their disproportionate enrollment in these programs. Results from this study will lay the foundation for subsequent research aiming to tie changes in health care utilization due to cost sharing policies to children's health status and health outcomes.