What Parents Say About Access to Care and How it Affects Decisions Regarding Enrollment in Medicaid

1
What Parents Say About Access to Care and How it
Affects Decisions Regarding Enrollment in
Medicaid and SCHIP Presented to Academy
Health 04 San Diego, CA

• Presented by Ian Hill, MPA, MSW
• Holly Stockdale, MPP, MPH
• The Urban Institute
• With
• Marilynn Evert
• Kathleen Gifford
• Health Management Associates, Inc.
• 6 June 2004

Research supported by the Robert Wood Johnson
Foundation
2
Background/Purpose

• Number of children without health insurance has
  declined in recent years, yet many eligible kids
  remain uninsured
• Covering Kids and Families (CKF) initiative
  funded by Robert Wood Johnson Foundation to
  support outreach and enrollment efforts
• CKF Evalulation designed to assess contribution
  to coverage
• Through focus group component, we set out to
  examine how parents experiences with access
  affect their decisions to enroll their children
  in coverage

3
Study Design

• 13 groups in 5 citiesBoston, Denver, Los
  Angeles, Mena, San Antonio
• Cities selected to represent both good and
  bad access environments and geographic
  diversity 1 rural site included
• Two types of groups parents of kids enrolled in
  Medicaid/SCHIP parents of uninsured kids (138
  parents, total)
• 3 Spanish-speaking groups in Denver and LA
• Participants recruited with help of CKF grantees

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Issues Explored

• Access to care
• Out-of-pocket costs
• Satisfaction with care
• Past experiences insured, uninsured, privately
  insured
• How/what parents heard about Medicaid and SCHIP
• Experiences with Medicaid/SCHIP enrollment and
  renewal
• Values regarding health insurance
• How access experiences affect enrollment decisions

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Access to Primary Care

• Medicaid and SCHIP
• Access to primary care described as good
• There are lots of doctors on the list I get
  from MassHealth (Boston)
• I found my doctor through the Healthy Families
  directory (LA)
• Though some faced geographic barriers
• I do find it difficult to get to the provider
  because of transportation. (LA)
• Parents in Boston Mena used private physicians,
  while those in Denver, LA, and San Antonio relied
  on public clinics

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Access to Primary Care (cont.)

• Uninsured
• Experiences also quite good, but some parents
  experienced long waits discontinuity of care,
  especially in public clinics
• My doctor continued to see my child until I
  got her insurance. (Boston)
• My local doctors are very good about seeing
  uswe have a relationship. (Mena)
• It makes a big difference where you go. (At
  the clinic) you sit and wait all day. (San
  Antonio)
• You dont feel at ease because its always a
  different doctor Each time you go to the clinic,
  its like starting over again. (LA)

7
Dental and Specialty Care

• For parents of insured and uninsured children,
  dental and specialty care were more difficult to
  access
• For dental, problems with availability, accepting
  Medicaid
• It is difficult to find a dentist who accepts
  MassHealth, and usually we have to pay out of
  pocket. (Boston)
• Im going to Tijuana right now for a dentist.
  Im paying out of pocket, but it is cheaper
  there. (LA)
• For specialty, difficulty navigating systems,
  long travel distances, long waits
• If you need anything other than a regular
  doctor, you have to go to Little Rock or Fort
  Smith. (Mena)

8
Health Care Costs and Cost Sharing

• Dramatic differences between insured and
  uninsured
• Medicaid and SCHIP
• Cost sharing considered very affordable
• Copaysare fine the 5 doesnt make me think
  twice about seeking care. (Boston)
• Its actually nicemakes you feellike youre
  doing your part. (Mena)
• Uninsured
• Parents frequently delayed care due to inability
  to pay
• You dont take them unless you have tounless
  its an emergency. (Denver)
• It makes me feel horrible to know that my
  daughter has a 105 degree fever and all I can do
  is cool her down with rags. (Denver)

9
Satisfaction with Care

• Satisfaction levels generally very high,
  especially among parents with kids on Medicaid
  and SCHIP
• Theres nothing better than MassHealth.
  (Boston)
• Were very satisfied. The pediatricians are
  thorough and we relate very well to them. (San
  Antonio)
• Uninsured parents more likely to express
  dissatisfaction with long waits, rude service,
  lack of personal attention
• They dont even want to talk to you! Its one
  bad experience after another. (Los Angeles)
• However, Boston and Mena uninsured reported good
  experiences which could be attributed to strong
  personal relationships with physicians

10
Special Access Issues for Spanish-Speaking
Families

• Generally, Spanish-speaking parents had similar
  experiences as English-speaking parents
• However, additional issues related to language
  barriers and discrimination were common
• I could not get an appointment because they
  claimed nobody in the office could speak Spanish.
  But I think they could (Denver).
• I fought to get a worker who understands me
  because I dont know what he is telling me and he
  does not know what I am telling him. (Los
  Angeles)

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How/What Parents Heard about Medicaid/SCHIP

• HOW friends, DSS caseworkers, social service
  agencies, hospitals, FQHCs, schools, TV radio
• WHAT mostly negative
• I heard you have to give them information on
  your life history every 6 months (Denver).
• I was hesitant to apply because I heard they
  investigated income (Los Angeles).
• We thought ARKids was a scam, at first. (Mena)
• Exception Boston, where parents heard such
  positive things as they pay for everything and
  its accepted everywhere

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Enrollment Experiences

• SCHIP application process described as easier
  than Medicaid
• Healthy Families keeps it simple. They only
  want to know your kids information (Los
  Angeles).
• It was so easy I dont remember it. (Mena)
• Frustrations with Medicaid application included
  too many personal questions, long waits for
  processing, and feeling that the process is
  complicated and degrading
• The social services department was not very
  helpful or sympathetic to my case. (Denver)
• Its humiliating to have to go to DPSS. (Los
  Angeles)
• Case workers are overloaded and we dont get
  our cards on time (Denver)
• Its a long wait, and a lot of paperwork that
  you fill out over and over (San Antonio)

13
Renewal Experiences

• Most parents with insured children said renewal
  was easy
• It was easyall the information was already
  there. (Los Angeles)
• Its so easy, you might forget to do it.
  (Mena)
• Most of the paperwork can be handled by mail
  or fax. (San Antonio)

14
Special Enrollment Issues for Spanish-Speaking
Parents

• Spanish-speaking parents described similar
  experiences as English-speakers, but also raised
  serious issues re language and discrimination
• I did not call the number on the TV because I
  was afraid there would be no one to answer my
  questions in Spanish. (Denver)
• I had a problem when I tried to apply for
  Medicaid. The social workers did not cooperate
  with methey would make excuses. (Los Angeles)
  
• Additional issues surfaced related to public
  charge
• They say that if you get help from the
  government, you will always have a mark saying
  that you asked for help. So I have not applied.
  (Los Angeles)

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What Parents Value About Health Insurance

• Unanimously parents valued health insurance
• It provides you with peace of mind, knowing
  that you can care for your kids if they get
  sick. (Boston)
• It takes the stress away. (Denver)
• Insurance gives me the wherewithal to keep my
  child healthy, to keep up with his shot and
  visits. (Denver)
• It takes cost out of the picture, and allows me
  to get care that I can afford. (Mena)
• It allows me to go to any hospital, or any
  doctor, and get better customer service. (San
  Antonio)

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How Access Experiences Affect Enrollment Decisions

• No matter how difficult families found
  application/renewal, and no matter what problems
  were encountered accessing care, virtually all
  parents said they would continue to seek coverage
• It is absolutely worth the effort. (San
  Antonio)
• You go through one day of burden for the good
  of your kids. (San Antonio)
• Youve got to do it. Youre desperate without
  health insurance. (Los Angeles)

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Conclusions

• Many positive findings
• Kids in Medicaid/SCHIP enjoy good access to care
• Uninsured kids also mostly able to obtain care
• Great value placed on health insurance
• Parents unanimous in believing health insurance
  was worth it regardless of hassles with
  applications, or problems with access

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Conclusions (cont.)

• Clearly, though, issues remain to be addressed
• Dental and specialty care more problematic to
  access, for both insured and uninsured groups
• Out-of-pocket costs for uninsured pose serious
  barrier to use
• Medicaid application process still overly
  complex/frustrating
• Spanish-speaking families confront numerous
  additional barriers, in both language and
  perceived discrimination
• Next Steps Recognizing limitations of focus
  groups, CKF evaluation will assess the impacts of
  access on enrollment quantitatively