What Parents Say About Access to Care
and How it Affects Decisions Regarding
Enrollment in Medicaid and SCHIP
Background/Purpose
i Number of children without health insurance has
declined in recent years, yet many eligible kids remain
uninsured
Presented to: Academy Health ’04
San Diego, CA
i Covering Kids and Families (CKF) initiative funded by Robert
Wood Johnson Foundation to support outreach and enrollment
efforts
i CKF Evalulation designed to assess contribution to coverage
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
i Through focus group component, we set out to examine
how parents’ experiences with access affect their
decisions to enroll their children in coverage
Research supported by the Robert Wood Johnson Foundation
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Study Design
Issues Explored
i 13 groups in 5 cities—Boston, Denver, Los Angeles,
Mena, San Antonio
i Access to care
i Cities selected to represent both “good” and “bad”
access environments and geographic diversity; 1
rural site included
i Satisfaction with care
i Out-of-pocket costs
i Past experiences: insured, uninsured, privately
insured
i Two types of groups: parents of kids enrolled in
Medicaid/SCHIP; parents of uninsured kids (138
parents, total)
i How/what parents heard about Medicaid and SCHIP
i 3 Spanish-speaking groups in Denver and LA
i Experiences with Medicaid/SCHIP enrollment and
renewal
i Participants recruited with help of CKF grantees
i Values regarding health insurance
i How access experiences affect enrollment decisions
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Access to Primary Care
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Access to Primary Care (cont.)
i Medicaid and SCHIP
Uninsured
iExperiences also quite good, but some parents
experienced long waits & discontinuity of care,
especially in public clinics
iAccess to primary care described as “good”
“There are lots of doctors on the list I get from
MassHealth” (Boston)
“My doctor continued to see my child until I got her
insurance.” (Boston)
“I found my doctor through the Healthy Families
directory (LA)
“My local doctors are very good about seeing us…we have a
relationship.” (Mena)
iThough some faced geographic barriers
“I do find it difficult to get to the provider because of
transportation.” (LA)
“It makes a big difference where you go. (At the clinic) you sit
and wait all day.” (San Antonio)
i Parents in Boston & Mena used private physicians,
while those in Denver, LA, and San Antonio relied
on public clinics
“You don’t feel at ease because it’s always a different
doctor… Each time you go to the clinic, it’s like starting over
again.” (LA)
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Health Care Costs and Cost Sharing
Dental and Specialty Care
i Dramatic differences between insured and uninsured
i For parents of insured and uninsured children, dental and
specialty care were more difficult to access
i Medicaid and SCHIP:
i Cost sharing considered very affordable
“Copays…are fine; the $5 doesn’t make me think twice
about seeking care.” (Boston)
i 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)
“It’s actually nice…makes you feel…like you’re doing
your part.” (Mena)
“I’m going to Tijuana right now for a dentist. I’m paying out
of pocket, but it is cheaper there.” (LA)
i Uninsured:
i For specialty, difficulty navigating systems, long travel
distances, long waits
i Parents frequently delayed care due to inability to pay
“You don’t take them unless you have to…unless it’s
an emergency.” (Denver)
“If you need anything other than a regular doctor, you have
to go to Little Rock or Fort Smith.” (Mena)
“ 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)
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Special Access Issues for Spanish
Families
Satisfaction with Care
i Satisfaction levels generally very high, especially
among parents with kids on Medicaid and SCHIP:
Speaking
i Generally, Spanish-speaking parents had similar
experiences as English-speaking parents
“There’s nothing better than MassHealth.” (Boston)
“We’re very satisfied. The pediatricians are thorough and
we relate very well to them.” (San Antonio)
i However, additional issues related to language barriers
and discrimination were common
i Uninsured parents more likely to express
dissatisfaction with long waits, rude service, lack of
personal attention
“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
don’t know what he is telling me and he does not know
what I am telling him.” (Los Angeles)
“They don’t even want to talk to you! It’s one bad
experience after another….” (Los Angeles)
i However, Boston and Mena uninsured reported good
experiences which could be attributed to “strong
personal relationships” with physicians
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How/What Parents Heard about
Medicaid/SCHIP
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Enrollment Experiences
i SCHIP application process described as easier than Medicaid
i HOW: friends, DSS caseworkers, social service agencies,
hospitals, FQHCs, schools, TV & radio
i WHAT: mostly negative
“Healthy Families keeps it simple. They only want to know
your kids information (Los Angeles).”
“It was so easy I don’t remember it.” (Mena)
“I heard you have to give them information on your life
history every 6 months (Denver).”
i Frustrations with Medicaid application included: too many
personal questions, long waits for processing, and feeling that
the process is “complicated” and “degrading”
“I was hesitant to apply because I heard they investigated
income (Los Angeles).”
“The social services department was not very helpful
or sympathetic to my case.” (Denver)
“We thought ARKids was a scam, at first.” (Mena)
“It’s humiliating to have to go to DPSS.” (Los Angeles)
i Exception: Boston, where parents heard such positive things
as “they pay for everything” and “it’s accepted everywhere”
“Case workers are overloaded and we don’t get our
cards on time…” (Denver)
“It’s a long wait, and a lot of paperwork that you fill out
over and over…” (San Antonio)
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Special Enrollment Issues for Spanish
Speaking Parents
Renewal Experiences
i Most parents with insured children said renewal was
easy
i Spanish-speaking parents described similar
experiences as English-speakers, but also raised
serious issues re language and discrimination
“It was easy…all the information was already
there.” (Los Angeles)
“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 me…they would make
excuses.” (Los Angeles)
“It’s so easy, you might forget to do it.” (Mena)
“Most of the paperwork can be handled by mail
or fax.” (San Antonio)
i 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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How Access Experiences Affect Enrollment
Decisions
What Parents Value About Health Insurance
i 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
iUnanimously 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)
“It is absolutely worth the effort.” (San Antonio)
“Insurance gives me the wherewithal to keep my child
healthy, to keep up with his shot and visits.” (Denver)
“You go through one day of burden for the good of your kids.”
(San Antonio)
“It takes cost out of the picture, and allows me to get care
that I can afford.” (Mena)
“You’ve got to do it. You’re desperate without health
insurance.” (Los Angeles)
“It allows me to go to any hospital, or any doctor, and get
better customer service.” (San Antonio)
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Conclusions
Conclusions (cont.)
iMany positive findings:
iClearly, though, issues remain to be addressed
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• 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
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
Next Steps: Recognizing limitations of focus
groups, CKF evaluation will assess the
impacts of access on enrollment
quantitatively
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