Medicaid Expansion and Child Maltreatment Rates: A “Natural Experiment”

Abstract

Background Child maltreatment impacts a large number of children and has negative consequences through adulthood. Only a few programs and policies that aim to prevent child physical abuse and neglect have proven to be consistently effective. Policies and programs that address some of the risk factors for physical abuse and neglect (e.g., poverty, limited parental access to physical and mental health care) have been proposed as a means to prevent child maltreatment indirectly. The recent Patient Protection and Affordable Care Act (ACA) Medicaid expansion has been associated with improved adult financial stability and access to physical and mental health care. By impacting these parental factors, the Medicaid expansion may have also impacted child physical abuse and neglect outcomes. Since Medicaid expansion did not happen in all states or at the same time, this allowed for a comparison not just of maltreatment outcomes within states that expanded Medicaid before and after the expansion occurred, but also for a comparison of the same maltreatment outcomes between states that did expand Medicaid and those that did not as part of a “natural experiment.” Objective Determine whether the ACA Medicaid expansion was associated with a decreased rate of child physical abuse and neglect. Methods We conducted an observational study using data from the National Child Abuse and Neglect Data System (NCANDS) Child Files to evaluate rates of reported abuse and neglect for children under the age of 6 years over a 7-year period, from 2010 through 2016. We also used data available through the Henry J. Kaiser Family Foundation to evaluate state-level changes in Medicaid coverage proportions for parents as a possible intermediate step in the association between Medicaid expansion policies and child maltreatment outcomes. A difference-in-difference analysis was conducted in which the change in rates of physical abuse and neglect before and after expansion of Medicaid in states where Medicaid expansion occurred were compared to the change in rates seen in states that did not expand Medicaid on or after January 1st 2014 controlling for several state-level measures including unemployment and teenage birth rates. Results Medicaid coverage for adults with dependent children increased after 2014 by 2.3% in the states that did not expand Medicaid and by 3.7% in the states that did. The states that did not expand Medicaid saw a decrease in the Medicaid eligibility cutoff for parents of 11 percentage points of the FPL whereas the states that did expand saw the eligibility cutoff increase by 36.9 percentage points of the FPL. The proportion of parents covered by Medicaid was found to increase annually (p=0.01) and was positively associated with Medicaid expansion status (p=0.04). When comparing the years 2013 and 2016, Medicaid expansion was found to be associated with a significant increase in %FPL Medicaid eligibility (p<0.01). There was not a statistically significant association between having expanded Medicaid and the combined rate of physical abuse and neglect or the rate of physical abuse. After adjusting for several covariables, having a Medicaid expansion policy was associated with having on average 120 fewer reported neglect cases per 100,000 children (-120.1 per 100,000, p-value = 0.02). Conclusions The association between Medicaid expansion and a relatively lower rate of child neglect reports indicates that the ACA may have had far-reaching impacts on children beyond simply providing health insurance to a larger portion of the American population. Our findings may support utilizing social policies as a means of preventing child neglect.