Do Access Experiences Affect Parents' Decisions to Enroll Their Children in Medicaid and SCHIP? Findings from Focus Groups with Parents

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Abstract

For the Robert Wood Johnson Foundation's Covering Kids and Families evaluation (CKF), researchers conducted focus groups to explore parents' experiences accessing health care for their children, and to assess whether these experiences affected decisions to enroll their children in Medicaid or the State Children's Health Insurance Program (SCHIP). In each community, groups were conducted with parents of children insured by Medicaid or SCHIP and parents of uninsured children. Researchers concluded that even when parents encountered problems accessing care, very few indicated that this discouraged them from enrolling their children into Medicaid or SCHIP, or from renewing their children's public coverage.

Introduction

Since the late 1980s, national and state policymakers have undertaken significant efforts to broaden health insurance coverage for low-income children. Beginning with a series of expansions of Medicaid eligibility for pregnant women and children, these efforts culminated in 1997 with the creation of the State Children's Health Insurance Program (SCHIP). At a time when there were approximately 10 million children without health insurance in the United States, SCHIP gave states $40 billion over 10 years to expand coverage to low-income children. Since then, aggressive outreach efforts and dramatic eligibility simplifications have fueled strong rates of enrollment in both SCHIP and Medicaid; the number of children without health insurance declined by nearly 2 million and the rate of uninsurance fell from 23 to 16 percent. Yet, despite this reduction, nearly 8 million children remained uninsured in 2002 even though more than half of these children were estimated to be eligible for Medicaid or SCHIP coverage. Therefore, it is important to understand the reasons why children are not being enrolled into the programs for which they are eligible.

Recent research demonstrates that knowledge gaps among parents partially explain why low-income children remain without health insurance. For example, a 2003 study showed that nearly 30 percent of low-income parents had not heard of SCHIP and 40 percent did not understand that their children could be eligible for health coverage even if they were not enrolled in welfare. Additionally, an estimated 7 percent of uninsured children lack coverage because their parents do not think they need it.

However, little research to date has explored whether access barriers also influence parents' decisions about whether or not to participate in Medicaid and SCHIP. In other words, could some portion of uninsured children live in families that have had prior negative experiences attempting to access care under Medicaid and SCHIP, so negative that they discouraged these parents from enrolling their eligible children in the programs? One study suggests that this might be the case; an assessment of the Robert Wood Johnson Foundation Covering Kids Initiative found that some parents' negative experiences accessing care in their local communities undermined their confidence in Medicaid and SCHIP, thereby dissuading them from enrolling their children into these programs.

However, the vast majority of the research literature has found the reverse relationship—that Medicaid and SCHIP have beneficial effects on access to care for the majority of enrollees. Numerous studies consistently show that publicly insured children, compared to their uninsured counterparts, are more likely to have a usual source of care, higher rates of use of preventive and primary care, and reduced unmet needs. Similarly, case studies and focus groups with parents conducted as part of two national evaluations of SCHIP found that access to care under the program is reportedly good.

To explore this discrepancy, better understand the relationship between access to care and enrollment in Medicaid and SCHIP, and gain insight into parents' experiences, attitudes, and perceptions regarding barriers to obtaining health care for their children, we conducted a series of focus groups with parents of children enrolled in Medicaid and SCHIP and parents of uninsured children. The research was conducted as part of the Covering Kids and Families Evaluation, funded by the Robert Wood Johnson Foundation.

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