A comparison of health care experiences for Medicaid and commercially enrolled children in a large, nonprofit health maintenance organization

Background.-Proponents of Medicaid managed care have argued that this type of care offers the potential to provide mainstream health care for poor chi ldren and the elimination of the 2-tier system of care that has long existe d for poor and nonpoor children. However, few studies have attempted to ass ess whether differences in access, utilization, and satisfaction exist betw een Medicaid and commercially sponsored children who are enrolled in the sa me managed care plan. Objective.-To systematically answer the following research question: Within the same large, nonprofit, group-model health maintenance organization (HM O), how do children enrolled in Medicaid compare with children enrolled com mercially across the domains of access, utilization, and satisfaction with care? Methods.-We compared access, satisfaction, and utilization of services betw een Medicaid and commercially sponsored children enrolled in Kaiser Permane nte of Northern California during 1998 through use of a telephone survey an d administrative data. Kaiser Permanente is a nonprofit, integrated, group HMO that serves 2.8 million members in more than 15 counties in northern Ca lifornia. The sample for this survey included 510 Medicaid- enrolled childr en and 512 commercially enrolled children. An overall response rate of 82% was achieved. Bivariate and multivariate analyses were used to compare Medi caid and commercially enrolled children. Results.-We found few differences between commercial and Medicaid enrollees across the domains of access, utilization, and satisfaction. Where access differences were present (problems in finding a personal care provider, pro blems getting care overall, and experiencing I or more barriers to care), t he differences favored Medicaid-enrolled children. That is, Medicaid enroll ees were reported to experience significantly fewer access problems and bar riers than commercial enrollees, even after adjustment for confounding fact ors. Only one difference was found between Medicaid and commercial enrollee s across the 6 utilization variables examined (volume of emergency departme nt visits), and no differences were found among the 4 satisfaction and 2 gl obal assessments of care received. Taken together, our results suggest that Medicaid-enrolled children experience as good as or better care than their commercially enrolled counterparts. However, there are other possible expl anations for our findings. It may be that families of Medicaid-enrolled chi ldren hold their care providers to a lower standard than families of commer cially enrolled children, given historic inequities in care between poor an d nonpoor families. In addition, some degree of selection bias may be prese nt in our sample, although that is true for both the Medicaid and commercia l populations. Conclusions.-Our findings suggest that large commercial HMOs are capable of eliminating the access barriers and stigma traditionally associated with t he Medicaid program. However, this conclusion must be tempered with the kno wledge that other explanations for our findings may also be at play.