Principal investigator: Bruno Benevit
Original title: Adult Medicaid benefit generosity and receipt of recommended health services among low-income children: The spillover effects of Medicaid adult dental coverage expansions
Author Brandy J. Lipton
Location of the Intervention: United States
Sample Size: 17.274 children
Sector: Health Economics
Primary Variable of Interest: Use of health services
Type of Intervention: Health insurance coverage
Methodology: DID, DDD, Event Study
Summary
Access to healthcare for children presents inequalities related to socioeconomic conditions. In this sense, public policies to expand health insurance coverage can minimize this situation. This study evaluated the impact of the coverage package of the program. Medicaid in reducing disparities in medical needs arising from income inequality. The results identified revealed that, by taking advantage of changes in dental benefits for adults at the state level over time, coverage is associated with increases of 14 and 5 percentage points, respectively, in the likelihood of a recent dental visit among parents and children directly exposed to the policy. The effects on children appear to be concentrated in children under 12 years of age.
- Policy Problem
Access to healthcare services for children presents inequalities related to socioeconomic conditions. Low-income children have a considerably lower chance of using healthcare services compared to their high-income peers, even for children insured by the program. MedicaidAlthough the health insurance plan offers coverage for dental services in all states of the United States, this behavior persists even for low-income children, where this group has a higher chance of experiencing dental problems and a lower chance of visiting the dentist (BERDAHL et al., 2016).
Beyond the health impacts, the reduced use of dental services can have negative effects on low-income children in other aspects of their lives, such as school attendance and academic performance (AGAKU et al., 2015). Therefore, a mechanism may exist between parental and child coverage, since health coverage involves a learning process and internalization of the benefits of insurance throughout its use, in addition to considerations regarding its fixed costs. In this sense, the design of the parental coverage package of the program... Medicaid has the potential to positively impact the health of low-income, uninsured children (LIPTON, 2021).
- Policy Implementation Context
O Medicaid It was instrumental in expanding access to dental services among low-income adults and children in the United States. According to the National Health Interview Survey (NHIS), between 2000 and 2013, the rate of dental visits among children from low-income families increased from 42% to 58%. However, even with this improvement, there was still a 15 percentage point difference compared to children from higher-income families. This indicates that, despite the preventive coverage provided by the program for children in all states, disparities in the use of dental care continued to exist. Furthermore, children with public insurance had consistently lower rates of dental visits than children with private insurance, with an 8 percentage point (pp) difference recorded in 2013.
These disparities reflect socioeconomic barriers to accessing dental care, even in populations covered by public insurance programs. Although the Medicaid While access to preventive services has been provided, low-income children, who face a higher risk of dental problems, continued to have less access to regular dental checkups. The increase in the use of dental services was more evident over time, but the gap compared to children from higher-income families persisted. The inclusion of pediatric dental services as an essential benefit under the Affordable Care Act (ACA) contributed to increased dental insurance coverage among children, but inequalities between socioeconomic groups were not completely overcome.
State programs for dental service coverage in Medicaid Dental coverage rates varied considerably between 2000 and 2013. During this period, between 23 and 28 states offered some type of dental coverage for adults beyond emergency services, while 17 states modified their policies. Approximately 61,6% of parents enrolled in the program had dental coverage during this period, but this percentage fell from 74,6% in 2000 to 44,2% in 2013 (LIPTON, 2021). For children, all states were required to provide full dental coverage through the benefit. Early and Periodic Screening, Diagnosis and Treatment (EPSDT), which included regular checkups, restorations, and treatment of infections and pain. Children enrolled in Children's Health Insurance Program (CHIP) in states with separate programs also had access to dental services needed to prevent disease and treat emergency conditions.
- Evaluation Details
The study used data from the NHIS, a repeated and representative cross-sectional survey of the non-institutionalized civilian population of the United States. Each family member responded to the survey, with one adult and one child per household providing more detailed information. For the study, a restricted version of the survey, linked to dental coverage policies for adults, was used. Medicaid between 2000 and 2013. The main outcome analyzed was whether the child had visited the dentist in the last six months, with the information being provided by an adult family member for children aged 1 to 17 years. The choice of this criterion was based on recommendations from American Dental Association and the American Academy of Pediatric DentistryIn addition, the survey included questions about the need for unmet dental care due to financial difficulties.
The child sample consisted of 17.274 children aged 1 to 17 years, with at least one parent co-resident and registered in the program. Medicaid and with complete data on dental visits. Children from families who received supplemental social security benefits in the previous year were excluded, as their parents were likely eligible for the program due to a disability. The majority of children (94%) were enrolled in the Medicaid or in the CHIP, indicating more accessible eligibility rules for children. For the parent analysis, the sample included 12.167 adults aged 22 to 64 enrolled in Medicaid, with at least one co-resident child under 18 years of age. Adults under 22 years of age were not considered in the sample, given that this group is eligible for dental coverage until age 20 through the EPSDT program. Medicaid.
- Method
The Difference-in-Differences (DID) method was used to analyze the effects of changes in dental coverage policies. Medicaid Over time, states that altered these policies were compared with those that did not. The main premise of DID is that, in the absence of a policy change, the trends in outcomes in the treated states would have paralleled those of the control states. The model was established to control for fixed state characteristics and national trends that could simultaneously affect policies and outcomes. With this approach, the direct effects of adult dental coverage policies after policy implementation were isolated by analyzing individuals over time.
Additionally, the event study method was employed to investigate the evolution of the effects of changes in dental policies over time. The rationale for this empirical strategy lies in capturing the variation at the moment each state modified its coverage, measuring the effects of each period before and after implementation. This approach also allowed us to assess whether the hypothesis of parallel trends before the policy, fundamental to the validity of the DID method, is valid, as well as to identify how the effects developed for each period after its implementation.
As a robustness approach, the study presented the intention-to-treat (ITT) estimation to circumvent possible selection biases when analyzing the impact of changes in dental coverage. Instead of focusing only on the direct beneficiaries of MedicaidAll individuals with low income or low levels of education were included in the analysis. The aim of this approach was to ensure that the results reflected the average effect of the policy, regardless of actual participation in it. Medicaid, minimizing biases resulting from changes in sample composition.
Finally, the program's impacts were estimated using the Triple Difference (DDD) method. This added an extra layer to the DID method, comparing the differences in outcomes between treated and untreated groups within the same states. In this way, this modeling sought to control for temporal factors that could have influenced all state residents similarly, as well as identify indirect effects, such as the policy's impact on families not directly eligible for the program. MedicaidHowever, they could be influenced by parents who passed on information about dental care.
- Main results
The main results using the DID method revealed that the introduction of dental benefits through the program Medicaid For adults, this resulted in a 13,8 percentage point increase in the likelihood of an adult having had a dental appointment in the last year, representing a 27% increase compared to the average number of visits, which was 51,5%. When considering subgroups, the effect was more pronounced among women (15,4 percentage points) compared to men (8,2 percentage points). For parents with fewer children, the effects were also more evident. In children, the increase ranged from 3,8 to 5,1 percentage points in the likelihood of an appointment in the last six months, an increase of around 11% compared to the control group. Considering other subgroups, higher increases were observed, especially when considering children aged 1 to 11 years (7,2 percentage points). Furthermore, the analysis revealed that low-income families experienced a reduction in the need for emergency treatments and an increase in the use of preventive services, regardless of age or family composition. These results suggest that the policy not only increased access to dental care, but also improved the overall quality of dental health among beneficiaries.
Regarding the intensive use of MedicaidA significant increase was observed in the number of days that adults and children remained covered by the program. This increase in exposure time to the program favored more frequent access to dental services, resulting in a noticeable improvement in oral health visits. For children, the data indicated that those with a greater number of accumulated years in the program... Medicaid They reported more regular visits to the dentist, suggesting a positive effect of continuous coverage.
Using the event study method, a cumulative impact of the policy on dental visits was identified for both adults and children. In the first year of policy implementation, there was a 4,6 percentage point reduction in parents' dental visits, indicating an initial adaptation. However, in subsequent years, a decline of 9,6 percentage points to 14,0 percentage points in their visits was observed. Among children, the effects were smaller initially, with a 3,1 percentage point reduction, but increased to 6,4 percentage points two years after the policy change.
The results using the DDD method reinforced the evidence identified previously. When incorporating an intrastate control group, the effects observed in parents remained significant, although slightly smaller compared to those estimated by the DID. Among children, the impact was also maintained, with a slight reduction observed when using a low-income control group.
- Lessons in Public Policy
In this article, the authors investigated the impact of coverage of Medicaid Regarding the dental health of insured families, the results showed that the expansion of the program significantly increased access to dental care, resulting in improved oral health among beneficiaries. The analysis also revealed that children from low-income families experienced a reduction in the need for emergency treatments and an increase in the use of preventive services, regardless of age or family composition.
The evidence from this study provides relevant insights into the effects of coverage of Medicaid In dental health, they inform policymakers about the intra-family spillover effects of the program, especially for families in situations of socioeconomic vulnerability. Furthermore, they highlight the potential of policies that prioritize preventive care and the importance of ensuring continuity of coverage, aiming to improve population health and reduce the costs associated with emergency care.
References
AGAKU, IT et al. Association between unmet dental needs and school absenteeism because of illness or injury among US school children and adolescents aged 6–17 years, 2011–2012. Preventive Medicine, v. 72, p. 83–88, mar. 2015.
BERDAHL, T. et al. Annual Report on Children's Health Care: Dental and Orthodontic Utilization and Expenditures for Children, 2010–2012. Academic Pediatrics, v. 16, n. 4, p. 314–326, May 2016.
LIPTON, BJ Adult Medicaid benefit generosity and receipt of recommended health services among low-income children: The spillover effects of Medicaid adult dental coverage expansions. Journal of Health Economics, 2021.
