A comparison of health care experiences for medicaid and commercially enrolled children in a large, nonprofit health maintenance organization.
BACKGROUND
Proponents of Medicaid managed care have argued that this type of care offers the potential to provide mainstream health care for poor children and the elimination of the 2-tier system of care that has long existed for poor and nonpoor children. However, few studies have attempted to assess whether differences in access, utilization, and satisfaction exist between Medicaid and commercially sponsored children who are enrolled in the same managed care plan.


OBJECTIVE
To systematically answer the following research question: Within the same large, nonprofit, group-model health maintenance organization (HMO), how do children enrolled in Medicaid compare with children enrolled commercially across the domains of access, utilization, and satisfaction with care?


METHODS
We compared access, satisfaction, and utilization of services between Medicaid and commercially sponsored children enrolled in Kaiser Permanente of Northern California during 1998 through use of a telephone survey and administrative data. Kaiser Permanente is a nonprofit, integrated, group HMO that serves 2.8 million members in more than 15 counties in northern California. The sample for this survey included 510 Medicaid-enrolled children and 512 commercially enrolled children. An overall response rate of 82% was achieved. Bivariate and multivariate analyses were used to compare Medicaid and commercially enrolled children.


RESULTS
We found few differences between commercial and Medicaid enrollees across the domains of access, utilization, and satisfaction. Where access differences were present (problems in finding a personal care provider, problems getting care overall, and experiencing 1 or more barriers to care), the differences favored Medicaid-enrolled children. That is, Medicaid enrollees were reported to experience significantly fewer access problems and barriers than commercial enrollees, even after adjustment for confounding factors. Only one difference was found between Medicaid and commercial enrollees across the 6 utilization variables examined (volume of emergency department visits), and no differences were found among the 4 satisfaction and 2 global assessments of care received. Taken together, our results suggest that Medicaid-enrolled children experience as good as or better care than their commercially enrolled counterparts. However, there are other possible explanations for our findings. It may be that families of Medicaid-enrolled children hold their care providers to a lower standard than families of commercially enrolled children, given historic inequities in care between poor and nonpoor families. In addition, some degree of selection bias may be present in our sample, although that is true for both the Medicaid and commercial populations.


CONCLUSIONS
Our findings suggest that large commercial HMOs are capable of eliminating the access barriers and stigma traditionally associated with the Medicaid program. However, this conclusion must be tempered with the knowledge that other explanations for our findings may also be at play.
Newacheck
P W
PW
Institute for Health Policy Studies, University of California, San Francisco, CA 94118, USA. pauln@itsa.ucsf.edu
Lieu
T
T
Kalkbrenner
A E
AE
Chi
F W
FW
Ray
G T
GT
Cohen
J W
JW
Weinick
R M
RM
D000293:Adolescent; D002140:California; D002648:Child; D002662:Child Health Services / Q000191:economics* / Q000706:statistics & numerical data; D002675:Child, Preschool; D003362:Cost-Benefit Analysis; D005260:Female; D019538:Health Care Surveys; D006279:Health Maintenance Organizations / Q000191:economics* / Q000706:statistics & numerical data; D006297:Health Services Accessibility / Q000191:economics* / Q000706:statistics & numerical data; D006301:Health Services Needs and Demand / Q000191:economics / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008484:Medicaid / Q000191:economics* / Q000706:statistics & numerical data; D015999:Multivariate Analysis; D009939:Organizations, Nonprofit; D011336:Probability; D012494:Sampling Studies