Abstract
The objective of this study is to use data from the National Survey of Children with Special Health Care Needs (NS-CSHCN) to test whether Medicaid physician fees are correlated with access to health services and adequacy of insurance coverage among CSHCN. We start with a difference-in-differences method, comparing the effects of Medicaid physician fees on outcomes of publicly-insured children in states that raised fees vs. in states that did not. As our preferred specification, we then estimate a triple difference model using privately-insured children as the comparison group. Our findings indicate that raising the Medicaid primary care fee level close to at least 90 percent of the Medicare level reduces the likelihood that publicly-insured CSHCN lack a usual source of care in a doctor’s office by about 15 percent. Fee increases are associated with improved access to specialty doctor care and large improvements in caregivers’ satisfaction with the adequacy of health insurance coverage among publicly-insured CSHCN. Results for some other access measures, such as global measures of having difficulties and delays accessing services, were mixed.
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Notes
This 44 percent figure includes children whose caregivers report have both public insurance and private insurance.
As we discuss later, only 42 states and DC are included in the study because of missing or incomplete fee ratio data for eight states (Arkansas, Delaware, Mississippi, Montana, Nebraska, Pennsylvania, Tennessee, and Wyoming).
Eleven states raised the fee ratio from under 0.90 to at least 0.90 (AZ ID KS LA NC ND NM NV OK VT WA). Thirteen states raised the fee ratio from under 0.80 to at least 0.80 (CO GA IA KS KY LA MD NM OK SC SD VA VT), and 33 states raised their fee ratio at least somewhat.
We estimated the main models without weights as well, and results were similar to those shown in the paper. Results available upon request.
The sample excludes children who have both private insurance and Medicaid, as well as children who were uninsured at any point during the past 12 months.
The primary care fee index does not distinguish between payments for pediatric versus adult primary care.
Physicians may anticipate Medicaid fee changes in the future, and may adjust their decisions accordingly. A limitation of this study is we cannot test for anticipation effects since we lack yearly data on CSHCN outcomes, as well as yearly data on Medicaid fees. Medicaid patients, however, typically comprise only a portion of a physician’s patient base (particularly for specialists) so it seems unlikely that a physician would make large-scale changes or practice investments (for example, hiring more support staff) in anticipation of future fee increases.
We also ran all the main models shown in Table 3 with the state’s Medicaid eligibility threshold for children as an additional covariate. Including this covariate has little effect on the findings so we do not include this covariate in the models shown in the paper.
We dropped 1607 observations with missing data for at least one of the child and family covariates. We tested whether this exclusion of observations with missing data affected our main DDD findings. We estimated the DDD models without covariates using the main analysis sample and then estimated these same models using a sample that includes observations with missing data on covariates. The findings are almost identical across the two samples, which gives us some confidence that our results are not affected by excluding observations with missing covariates.
Generally, in 2001, CSHCN face more access problems in treatment states (states that raised fees to the 0.90 threshold or higher) vs. in control states (states that did not raise fees to the 0.90 threshold or higher) (results available upon request). The magnitudes of these differences are small in some cases, but they are large in percentage terms for a few outcomes. There were no differences across treatment states vs. control states in adequacy of health insurance coverage. Severity of conditions is higher in treatment vs. control states. This pattern may suggest policy endogeneity—states may have responded to access problems among CSHCN by raising fees to a higher level. We cannot directly test for such policy endogeneity in the paper, and thus leave this question for future research.
We tested whether fee ratios affected participation in Medicaid. For this exercise, we use a DD model as in, for example, Table 3 based on Eq. (1), but we include both privately- and publicly-insured children in the sample (n = 48,405). We use “Publicly Insured” as the outcome and obtain the following insignificant estimate on the high fee variable: Coef. = −1.84, Robust Std. Error. = 2.02. This finding suggests that the main models in the paper are preferred to the ITT estimates since we do not find evidence that higher fee ratios are associated with Medicaid participation.
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Chatterji, P., Decker, S.L. & Huh, J. Medicaid physician fees and access to care among children with special health care needs. Rev Econ Household 20, 887–919 (2022). https://doi.org/10.1007/s11150-021-09575-6
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DOI: https://doi.org/10.1007/s11150-021-09575-6