Differential impact of recent Medicaid expansions by race and ethnicity

Objective. Between 1989 and 1995, expansions in Medicaid eligibility provided publicly financed health insurance to an additional 7 million poor and near-poor children. It is not known whether these expansions affected children's insurance coverage, use of health care services, or health status differently, depending on their race/ethnicity. The objective of this study was to examine, by race/ethnicity, the impact of the recent Medicaid expansions on levels of uninsured individuals, health care service utilization, and health status of the targeted groups of children. Methods. Using a stratified set of longitudinal data from the National Health Interview Surveys of 1989 and 1995, we compared changes in measures of health insurance coverage, health services utilization, and health status for poor white, black, and Hispanic 1- to 12-year-old children. To control for underlying trends over time, we subtracted 1989 to 1995 changes in these outcomes among nonpoor children from changes among the poor children for each race/ethnicity group. Measures of coverage included uninsured rates and Medicaid rates. Utilization measures included annual probability of visiting a doctor, annual number of doctor visits, and annual probability of hospitalization. Health status measures included self-reported health status and number of restricted-activity days in the 2 weeks before the interview. Differences in means were analyzed with the use of Student's t tests accounting for the clustering sample design of the National Health Interview Surveys. Results. Among poor children between 1989 and 1995, uninsured rates declined by 4 percentage points for whites, 11 percentage points for blacks, and 19 percentage points for Hispanics. Medicaid rates for these groups increased by 16 percentage points, 22 percentage points, and 23 percentage points, respectively. With respect to utilization, the annual probability of seeing a physician increased 7 percentage points among poor blacks and Hispanics but only 1 percentage point among poor whites (not significant) for children in good, fair, or poor health. Among those in excellent or very good health, the respective increases were 1 percentage point for poor whites (not significant), 7 percentage points for poor blacks, and 3 percentage points for poor Hispanics (not significant). Significant increases in numbers of doctor visits per year were recorded only for poor Hispanics who were in excellent or very good health, whereas significant decreases in hospitalizations were recorded for Hispanics who were in good fair or poor health. Measures of health status remained unchanged for poor children over time. The recorded decreases in uninsured rates and increases in Medicaid coverage remained robust to adjustments for underlying trends for all 3 race/ ethnicity groups. With respect to adjusted measures of utilization and health status, the only significant differences found were among poor blacks who were in good, fair, or poor health and who registered increases in the likelihood of hospitalization and in poor Hispanics who were in excellent or very good health and who registered decreases in the numbers of restricted-activity days. Conclusions. Recent expansions in the Medicaid program from 1989 to 1995 produced greater reductions in uninsured rates among poor minority children than among poor white children. Regardless of race/ethnicity, poor children did not seem to experience significant changes during the period of the expansions in either their level of health service utilization or their health status. Pediatrics 2001;108:1135-1142; Medicaid, health insurance, health status, health services.
ABBREVIATIONS. FPL, federal poverty level; NHIS, National Health Interview Surveys; AFDC, Aid to Families With Dependent Children. Expansions in the Medicaid program enacted by Congress during the past decade increased [...]