Children on Medicaid Shown to Wait Longer for Care

Children with Medicaid are far more likely than those with private insurance to be turned away by medical specialists or be made to wait more than a month for an appointment, even for serious medical problems, a new study finds.

Lower payments by Medicaid, delays in paying and red tape are largely to blame, researchers say.
The study, with findings that match anecdotal reports from other parts of the country, is one of only a few efforts to measure access to health care among people with Medicaid. Nationwide, those patients are caught between states’ threats to cut Medicaid payments and the Obama administration’s plans to use the program to cover more and more people as part of its health care law.
“There’s never been a study this comprehensive or this rigorous that actually measured access to specialty care, let alone children’s access,” said Dr. Karin V. Rhodes, an author of the study and director of emergency care policy research in the department of emergency medicine at the University of Pennsylvania.
The study used a “secret shopper” technique in which researchers posed as the parent of a sick or injured child and called 273 specialty practices in Cook County, Ill., to schedule appointments. The callers, working from January to May 2010, described problems that were urgent but not emergencies, like diabetes, seizures, uncontrolled asthma, a broken bone or severe depression. If they were asked, they said that primary care doctors or emergency departments had referred them.
Sixty-six percent of those who mentioned Medicaid-CHIP (Children’s Health Insurance Program) were denied appointments, compared with 11 percent who said they had private insurance, according to an article being published Thursday in The New England Journal of Medicine.
In 89 clinics that accepted both kinds of patients, the waiting time for callers who said they had Medicaid was an average of 22 days longer.
“It’s very disturbing,” Dr. Rhodes said. “As a mother, if I had a kid who was having seizures or newly diagnosed juvenile diabetes, I would want to get them in right away.”
With many states planning cuts in Medicaid, Dr. Rhodes said, public insurance programs were already being strained to the breaking point. “If we keep whittling away at them, it will hurt children and adults alike,” she said.
Other doctors said the issue was so pronounced that Dr. Rhodes’s findings were hardly surprising.
“This is a nationwide problem,” said Dr. Stephen Stabile, associate chief medical officer of the Ambulatory and Community Health Network at Cook County Health and Hospitals System.
Another physician not connected with the study, Dr. Judy Neafsey, medical director of the specialty care center at Stroger Hospital, part of Cook County’s public hospital system, said: “It’s interesting to think you even need a study to prove that. It’s pretty much common knowledge.”
Mike Claffey, a spokesman for the Illinois Department of Healthcare and Family Services, said by e-mail that the study “provides data that highlights an issue that has been and continues to be an area of focus for” his agency and Medicaid programs in all states.
In Illinois, according to Dr. Rhodes’s article, Medicaid will pay $99.86 for an office visit for a problem of “moderate severity,” compared with $160 from a private insurer. Many doctors said they could not keep their practices going if they accepted too many Medicaid patients.
And specialists affiliated with academic medical centers said they were willing to treat Medicaid patients but were under pressure from the medical centers to bring in more money by seeing more people with private insurance, Dr. Rhodes said.
This month, Dr. Rhodes and her colleagues had a similar study published in the journal Pediatrics, finding that dentists were far less likely to accept children with public insurance than those with private coverage, even for an urgent problem like a broken front tooth. Another study of hers uncovered patients’ difficulties in obtaining psychiatric care.
Dr. Rhodes said she became interested in access to care more than a decade ago, when, as an emergency room doctor, she kept seeing patients who did not belong in the emergency room but could not find treatment anyplace else.
Her current study of specialty care grew out of a lawsuit by health advocates against the state of Illinois, Memisovski v. Maram, on behalf of 600,000 children covered by Medicaid. In that case, a judge found in 2004 that children on Medicaid did not have the same access to preventive health care as did those with private insurance. The case led to higher payment rates and other changes in Illinois, and also a requirement that the state pay for a study of low-income children’s access to medical specialists.
Dr. Rhodes was asked to conduct the study.
“I was very disappointed to find this level of disparities,” she said.
The researchers focused on eight specialties: dermatology; otolaryngology (ear, nose and throat); endocrinology (for diabetes); neurology; allergy; pulmonology; psychiatry and orthopedics.
“The disparity held across every specialty that was tested,” Dr. Rhodes said. “This is systemic.”
Dr. Stabile said that poor people in Chicago could be treated at county hospitals, but that those in the suburbs had a much harder time finding providers who accepted Medicaid.
“And that’s where poor people are moving to around Chicago,” Dr. Stabile said, adding that the county system was trying to move more services to the suburbs.
Lisa Hannum, who lives in Schaumburg, about 30 miles from Chicago but still in Cook County, has three children who qualify for Medicaid because they were wards of the state before she adopted them. Over the years, she said, she has encountered multiple doctors who would not accept them as patients because they were on Medicaid. At times she just gave up and paid for their treatment herself. Just recently, she said, an urgent-care clinic declined to treat her daughter for a dog bite because the clinic did not accept Medicaid. For her son, an eye clinic did accept Medicaid, but it took nearly five months to provide the new eyeglasses he needed.
“People say: ‘Sure, I take insurance. Oh, I don’t take Medicaid,’ ” Ms. Hannum said. “I guess I’m lucky that my kids are almost never sick.”