Medicaid Expansion Tied to Lower Rates of Child Neglect, but Not Abuse

George W. Citroner

June 19, 2019

Medicaid expansion under the Affordable Care Act (ACA) is associated with a significant reduction in rates of child neglect, new research shows.

Investigators from the Seattle Children's Research Institute in Washington found significantly lower rates of child neglect in the 31 states that expanded Medicaid in 2014 compared with the 19 states that did not opt for Medicaid expansion.

"This study suggests an association between the ACA Medicaid expansion and reductions in the rate of screened-in reports made to CPS [Child Protective Services] for concerns of neglect in children younger than 6 years," write Emily C. B. Brown, MD, and colleagues.

The study was published online June 14 in JAMA Network Open.

Reducing Maltreatment Risk

Based on CPS data, estimates suggest approximately 5% of all children in the US are victims of physical abuse or neglect.

Previous research shows that ACA Medicaid expansion is associated with improved parental financial stability and greater access to mental health services — both important risk factors for child maltreatment.

"Because mental health issues and poverty are risk factors for child physical abuse and neglect, we wanted to see whether the Medicaid expansion was associated with changes in the rate of reports to Child Protective Services for abuse and neglect," Brown told Medscape Medical News.

"The fact that some states chose not to expand Medicaid meant that we could compare those states to the ones that did expand," she added.

For the study, the investigators compared pre- and post-Medicaid expansion state-level rates of child physical abuse and neglect from the National Child Abuse and Neglect Data Systems (NCANDS) from January 1, 2010 through December 31, 2016.

The study's primary outcome measure was the incidence rate of screened-in referrals for physical abuse or neglect per 100,000 children younger than 6 years, per year by state.

After adjusting for potential confounders, results showed that following Medicaid expansion there were 422 fewer cases of neglect per 100,000 children younger than 6 years of age (95% confidence interval [CI], −753 to −91) reported each year.

From 2013 to 2016, Medicaid coverage for adults with dependent children increased a median 1.9 % (interquartile range, 0.4% to 4.3%) in the states that did not expand Medicaid and 4.2% (interquartile range, 0.9% to 6.0%) in the states that did.

In states that expanded Medicaid, physical abuse rates for children younger than 6 years decreased by 68 cases per 100,000 children and neglect rate decreased by 336 cases per 100,000 children. 

Medicaid expansion was associated with lower rates of reported child neglect. However, the study showed no statistically significant reduction in the rate of child abuse.

Comparatively, states without Medicaid expansion showed a decreased rate of physical abuse of 35 cases per 100,000 and an increased rate of neglect by 90 cases per 100,000 for this age group.

However, there was no association between Medicaid coverage or Medicaid eligibility criteria and physical abuse or neglect rates.

Brown noted that the study had significant limitations.

"Medicaid delivery varies significantly from one state to the next. Since our study focused only on whether a state expanded Medicaid, we couldn't determine whether the association we found was related to specific aspects of different Medicaid programs," she said.

She also noted that the study was not designed to determine how Medicaid expansion might result in lower child physical abuse and neglect rates, but rather to ascertain whether there were any associations.

Brown speculated that the absence of an association between Medicaid expansion and a drop in physical abuse could because the study period may not have been long enough.

Need for Policy, Not Programs

In an accompanying editorial, Kristine Campbell, MD, Center for Safe and Healthy Families, Primary Children's Hospital, Salt Lake City, Utah, notes the study "adds to a small but growing stream of research in which the prevention of child maltreatment is the unanticipated bonus of a social policy rather than the primary objective of a prevention program."

She points out that the rapid reduction in child maltreatment in states that opted for Medicaid expansion is a promising response to policies intended to improve social determinants of health.

"What if the most effective, efficient and sustained approach to preventing child maltreatment is the adoption of policies that broadly improve social equity and public health, rather than the implementation of programs that specifically target child maltreatment prevention?" she writes.

Commenting on the findings for Medscape Medical News, Dana Dorfman, PhD, a New York City-based child, adolescent and adult psychotherapist who was not involved with the current study, said there is "no doubt" that Medicaid expansion had a positive effect on children's welfare.

In addition to the obvious advantages of health, medical availability, and accessibility to healthcare for impoverished families, there are other, more nuanced factors that contribute to improvements in mental and physical health, she noted.

"Because access to the medical community conveys both subtle and overt messages to recipients, including caregivers, that they are also cared for and looked after," Dorfman said. "This engendered feeling of protection and safety provided by the government reverberates throughout the family. Parents who feel supported and cared for are more likely to provide care and support for their children."

Dorfman said that, given the limitations of this study and the intergenerational nature of both abuse and neglect, she thinks that "a longitudinal study would be beneficial. While these findings are promising, it would be helpful to see if offering Medicaid impacted one generation's treatment of the next." 

The study was funded by the Helfer Society. Brown and coauthor Carole Jenny reported providing expert testimony, as part of their clinical responsibilities, in cases of alleged child maltreatment. Brown reported receiving grants from the Helfer Society during the conduct of the study.

Campbell reported that her institution receives financial compensation for expert witness testimony provided in cases of suspected child abuse for which she is subpoenaed to testify and reported receiving funding through the Interdisciplinary Research Leadership Program of the Robert Wood Johnson Foundation, the National Child Traumatic Stress Network, the Utah Department of Human Services, and the Primary Children’s Hospital Foundation. Dorfman has disclosed no relevant financial relationships.

JAMA Network Open. Published online June 14, 2019. Full text, Editorial

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