Reducing Child Health Disparities with Health Policies: Is Health Reform Enough?

Abstract

Understanding whether healthcare policies can narrow and eliminate racial/ethnic disparities in health care access and utilization is an important public health issue. This dissertation examines whether two reforms, the Massachusetts (MA) health care reform law (Chapter 58) and the Patient Protection and Affordable Care Act (ACA), reduced racial/ethnic-related disparities in health care access and utilization between Hispanic and NH-white children. The first aim of this study examined the long-term effects of the MA health reform on disparities in insurance access, utilization of care, and health status among Hispanic children compared to non-Hispanic white children. The second and third aims examined the short-term effects of the ACA on disparities among Hispanic children compared to non-Hispanic white children. The second aim evaluated the impact of the ACA on insurance access and utilization of health care, and the third aim examined ACA impacts on financial burden due to medical costs experienced by the child’s family. Data from the National Survey of Children’s Health and the National Health Interview Survey were evaluated before and after implementation of the MA health reform (aim 1) and the ACA insurance expansion in 2014 (aims 2 & 3). The study subjects were children ages 0 to 17 years old. The impact of insurance expansion through health reform on disparities was evaluated using a triple-difference (difference-in-difference-in-difference, or DDD) analysis, which controlled for events not captured by the covariates that can affect the outcomes. Each aim utilized a nonequivalent pretest/posttest comparison group study design. For the first aim, children living in Massachusetts were the intervention group, and children living in surrounding states (Rhode Island, New Hampshire, and Connecticut) were in the comparison group. For the second and third aim, the intervention group includes children who were not eligible for Medicaid/CHIP before reform and whose family income was <400% of the federal poverty level (FPL). The two comparison groups were composed of children eligible for Medicaid/CHIP before and after reform (the Medicaid/CHIP group), and children whose family income was ≥400% of the FPL (the 400% FPL group). The MA Health Reform did significantly narrow disparities between Hispanic and NH-white children for consistent health insurance coverage; no changes were evident for health outcome measures. The ACA significantly improved insurance coverage by approximately 4-percentage points only among children in the Medicaid/CHIP group for Hispanic and NH-white children. However, insurance coverage disparities between Hispanic and NH-white children did not change significantly after insurance expansion for the intervention and 400% FPL comparison groups. Family financial burden disparities were not evident between Hispanic and NH-white children and their families. However, there was a significant reduction in high financial burden for both racial/ethnic groups in the Medicaid/CHIP comparison group post-ACA insurance reform. This study found that after implementation of both health reforms, Hispanic children continue to fall behind NH-white children in having health insurance coverage and in utilizing preventive health care services. Additional interventions targeted at Hispanic families are needed to improve child health disparities in insurance access. Other reform efforts besides improving insurance access are also needed to improve disparities in preventive care utilization. This study underscores the need for quasi-experimental studies of racial/ethnic disparities in health and health care in the future.