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Medicaid and pediatric subspecialty care

Pediatric Research (2024)Cite this article

Medicaid and the Children’s Health Insurance Program (CHIP), essential public health insurance programs, together cover almost half of all US children and youth.1 Children from minoritized populations are particularly likely to have Medicaid/CHIP coverage. These programs enhance equity for US children, insofar as many low-income children of color would have gone without any coverage without them. These programs have well-documented health benefits, including short term (timely access to care, reductions in emergency department utilization, avoidable hospitalizations, and neonatal and child mortality),2 and long-term benefits (less chronic disease in adulthood, lower rates of teenage pregnancy, and higher high school graduation rates).3,4 Despite these strengths, Medicaid and CHIP perpetuate other inequities due to low payment rates and marked state variations in program eligibility, enrollment, networks, and payment, challenging children’s access to needed services, especially across state lines. These challenges set the Medicaid and CHIP programs apart from the Medicare program, with distinct differences in structure (state based vs. federal) and with Medicare payment generally much better than Medciaid. Other challenges include administrative issues, such as frequent eligibility redetermination and coverage exclusions. States with larger minority populations tend to have less generous Medicaid programs. These benefits and challenges face children who need subspecialty care, in both the outpatient and inpatient settings, and the providers that provide that care.

Much Medicaid/CHIP discussion has focused on primary care. For pediatric medical and surgical subspecialists, mostly based in hospitals serving children, the programs directly affect both the financing of hospitals and children’s access to subspecialty care. Children with chronic health conditions have even higher rates of public coverage than other US children, have higher needs for subspecialty care, and account for a larger percentage of Medicaid spending on children.5 Medicaid financing supports many pediatric hospitals, and low hospital fees substantially restrict hospital revenues.

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References

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Authors and Affiliations

  1. Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University School of Medicine, Chicago, IL, USA

    Jennifer K. Saper

  2. Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA

    Jean L. Raphael

  3. Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA

    Lisa J. Chamberlain

  4. Department of Pediatrics, MassGeneral Hospital for Children, Harvard Medical School, Boston, MA, USA

    James M. Perrin

Authors
  1. Jennifer K. Saper
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  2. Jean L. Raphael
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  3. Lisa J. Chamberlain
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  4. James M. Perrin
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Contributions

Dr. Saper conceptualized the commentary, drafted the initial manuscript, and reviewed and revised the manuscript. Drs. Raphael, Chamberlain, and Perrin conceptualized the commentary and critically reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

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Correspondence to James M. Perrin.

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Saper, J.K., Raphael, J.L., Chamberlain, L.J. et al. Medicaid and pediatric subspecialty care. Pediatr Res (2024). https://doi.org/10.1038/s41390-024-03275-4

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