Does Access to Public Health Insurance Prevent Child Maltreatment? Findings from Natural Experiments in the Policy Environment

Background & Purpose

Public health insurance has been found to improve child health and well-being in domains associated with child maltreatment by reducing adolescent birth rates and preventing child disability. Children are also less likely to receive health services in a timely manner without insurance. However, studies have yet to examine the effects of public health insurance policies on child maltreatment dynamics. Medicaid is the primary program that provides health insurance to the poor in the U.S. State children’s health insurance programs (SCHIP) insure low-income children whose family income is too high to qualify for Medicaid. Several policy variations exist across U.S. states that govern access to these programs: presumptive eligibility, which enables states to provide temporary coverage to children and pregnant women under Medicaid and CHIP until a formal eligibility determination can be made; requirements for face-to-face interviews in eligibility determination; joint family applications; and requirements for asset information at the time of application. We examine changes in these policies across states over time to identify the effects of policies that govern Medicaid and CHIP access on child maltreatment.   

Methods

Data and Sample. We examined the effects of changes in public health insurance policies on child maltreatment reports, victims, and foster care entries using state/year panel data from the National Child Abuse and Neglect Data System and the Adoption and Foster Care Reporting System from 2005-2014. Policy variables were drawn from the Kaiser Family Foundation’s Program on Medicaid and the Uninsured over the years 2005-2014. We adjust for a large number of state level covariates using data from the University of Kentucky Center for Poverty Research, the Current Population Survey, and the March Current Population Survey Annual Social and Economic Supplement (CPS-ASEC). We account for the nation’s opioid epidemic by adjusting for crude death rates due to substance overdose at the state level.

Analytic Approach. To estimate the causal effects of public health insurance policy changes on child maltreatment outcomes, we use difference-in-difference models, an approach that embeds policy changes as quasi-experiments in a regression model. We use state fixed effects to account for state mandated reporting laws, which did not change over the study period. All analyses were performed in STATA 15.

Results

States that exempted Medicaid applicants from face-to-face interviews had 5.6% fewer maltreatment reports when compared to states that required face-to-face interviews. States that provided presumptive eligibility in their SCHIP programs had 10.2% fewer maltreatment reports when compared to states without the provision. States without SCHIP programs had 18.4% more reports of child neglect when compared to states with SCHIP.

Conclusions and Implications 

Greater access to public health insurance improves families’ financial security given the high costs of health care and allows caregivers to address child health care needs that might otherwise go unmet. State policy changes that facilitate access to public health insurance appear to prevent child maltreatment, specifically by reducing the number of children reported to child protective services. Therefore, such policies should be considered in child maltreatment prevention efforts.