Differences in state Medicaid programs for children with medical complexity may lead to inequity in care

Medicaid eligibility and coverage for children with medical complexity varies widely by state, raising issues of health equity, especially if families cross state borders. State, according to a study from the Ann & Robert H. Lurie Children’s Hospital in Chicago published in the journal JAMA. Open network. The study focused on Medicaid programs for these children beyond traditional eligibility based on family income.

“State-by-state differences in Medicaid eligibility and coverage influence access to services for children with medical complexity, which can lead to delays in care, impacting health outcomes for these children” said lead author Jennifer Kusma, MD, MS, pediatrician at Lurie Children’s and pediatric instructor at Northwestern University Feinberg School of Medicine.

Children with medical complexity have at least one complex chronic illness resulting in functional limitations, family-identified health care needs, and dependence on medical technology. Due to the high health care costs for the therapies these children require, pathways have been created for children with medical complexity to qualify for Medicaid in addition to their parent’s employer insurance, based on medical criteria. These include the medically needy provision, waivers to cover the cost of institutional level care at home, and waivers focused on home and community services. States differ in whether they offer one or more of these options. States also differ on whether children with complex medical conditions are covered by Medicaid managed care programs or paid Medicaid programs, or a combination of these health plans.

The study used semi-structured interviews with 43 state Medicaid officials from 23 states and Washington, D.C., to clarify the differences in eligibility and coverage offered by state Medicaid programs for children with medical complexity.

Dr. Kusma and his colleagues found that the variation in state Medicaid programs for children with medical complexity can be profound. For example, while in one state these children may qualify for Medicaid coverage within months, in another state they may wait years to be covered.

“Our findings can inform future advocacy efforts regarding policy changes to meet the needs of these vulnerable children, recognizing that status differences may persist over time,” Dr. Kusma said.

Matthew Davis, MD, MAPP, and Carolyn Foster, MD, MSHS, both of Lurie Children’s, are study co-authors.

Research at the Ann & Robert H. Lurie Children’s Hospital in Chicago is conducted by the Stanley Manne Children’s Research Institute. The Manne Research Institute is focused on improving the health of children, transforming pediatric medicine, and ensuring a healthier future through the relentless pursuit of knowledge. Lurie Children’s is ranked among the nation’s top children’s hospitals by US News & World Report. It is the pediatric training ground of the Northwestern University Feinberg School of Medicine.

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Sharon D. Cole