Maternal and Child Health Journal

, Volume 16, Supplement 1, pp 51–60 | Cite as

Value for the Money Spent? Exploring the Relationship Between Expenditures, Insurance Adequacy, and Access to Care for Publicly Insured Children

  • Margaret S. Colby
  • Debra J. Lipson
  • Sarah R. Turchin


This study examines the relationship between total state Medicaid spending per child and measures of insurance adequacy and access to care for publicly insured children. Using the 2007 National Survey of Children’s Health, seven measures of insurance adequacy and health care access were examined for publicly insured children (n = 19,715). Aggregate state-level measures were constructed, adjusting for differences in demographic, health status, and household characteristics. Per member per month (PMPM) state Medicaid spending on children ages 0–17 was calculated from capitated, fee-for-service, and administrative expenses. Adjusted measures were compared with PMPM state Medicaid spending in scatter plots, and multilevel logistic regression models tested how well state-level expenditures predicted individual adequacy and access measures. Medicaid spending PMPM was a significant predictor of both insurance adequacy and receipt of mental health services. An increase of $50 PMPM was associated with a 6–7 % increase in the likelihood that insurance would always cover needed services and allow access to providers (p = 0.04) and a 19 % increase in the likelihood of receiving mental health services (p < 0.01). For the remaining four measures, PMPM was a consistent (though not statistically significant) positive predictor. States with higher total spending per child appear to assure better access to care for Medicaid children. The policies or incentives used by the few states that get the greatest value—lower-than-median spending and higher-than-median adequacy and access—should be examined for potential best practices that other states could adapt to improve value for their Medicaid spending.


Medicaid Health care expenditures Health care access Value 


  1. 1.
    Belli, P. C., Busreto, F., & Preker, A. (2005). Investing in children’s health: What are the economic benefits? Bulletin of the World Health Organization, 83(10), 777–784.PubMedGoogle Scholar
  2. 2.
    Case, A., Fertig, A., & Paxson, C. (2005). The lasting impact of childhood health and circumstance. Journal of Health Economy, 24(2), 365–389.CrossRefGoogle Scholar
  3. 3.
    Dowd, J. B., Zajacova, A., & Aiello, A. (2009). Early origins of health disparities: burden of infection, health, and socioeconomic status in U.S. children. Social Science and Medicine, 68(4), 699–707.PubMedCrossRefGoogle Scholar
  4. 4.
    Hayward, M. D., & Gorman, B. K. (2004). The long arm of childhood: the influence of early-life social conditions on men’s mortality. Demography, 41(1), 87–107.PubMedCrossRefGoogle Scholar
  5. 5.
    Jackson, M. I. (2009). Understanding the link between adolescent health and educational attainment. Demography, 46(4), 671–694.PubMedCrossRefGoogle Scholar
  6. 6. [Internet]. (2009). Menlo Park (CA): Kaiser Family Foundation; [2011; cited 2011 May 2]. Health insurance coverage of children 0–18 living in poverty (under 100 % FPL), states (2008–2009) and US [about 5 screens]. Available from:
  7. 7. [Internet]. Menlo Park (CA): Kaiser Family Foundation; [2011; cited 2011 May 2]. Total Medicaid spending, FY 2009; [about 9 screens]. Available from:
  8. 8.
    National Association of State Budget Officers. (2010). State expenditure report 2009 [Internet]. Washington (DC): National Association of State Budget Officers; [cited 2011 February 20]. Available from:
  9. 9.
    McGinnis, T., Berenson, J., & Highsmith, N. (2011). Increasing primary care rates, maximizing Medicaid access and quality [Internet]. Hamilton (NJ): Center for Health Care Strategies; [cited 2011 May 2]. Available from:
  10. 10.
    Kenney, G. M., Marton, J., Klein, A. E., Pelletier, J. E., & Talbert, J. (2011). The effects of Medicaid and CHIP policy changes on receipt of preventive care among children. Health Services Research, 46(1), 298–318.PubMedCrossRefGoogle Scholar
  11. 11.
    Cunningham, P., & Nichols, L. (2005). The effects of Medicaid reimbursement on the access to care of Medicaid enrollees: A community perspective. Medical Care Research and Review, 62(6), 676–696.PubMedCrossRefGoogle Scholar
  12. 12.
    Shen, Y., & Zuckerman, S. (2005). The effect of Medicaid payment generosity on access and use among beneficiaries. Health Services Research, 40(3), 723–744.PubMedCrossRefGoogle Scholar
  13. 13.
    Centers for Medicare & Medicaid Services. (2011). Medicare & Medicaid statistical supplement, 2009 edition. Table 13.18—Medicaid payments, children, by type of service: fiscal years 1975–2007 [Internet]. Baltimore: Centers for Medicare & Medicaid Services; [cited 2011 February 20]. Available from:
  14. 14.
    Hurley, R. E., & Somers, S. A. (2003). Medicaid and managed care: A lasting relationship? Health Affairs, 22(1), 77–88.PubMedCrossRefGoogle Scholar
  15. 15.
    Holahan, J., Zuckerman, S., Evans, A., & Rangarajan, S. (1998). Medicaid managed care in thirteen states. Health Affairs, 17(3), 43–63.PubMedCrossRefGoogle Scholar
  16. 16.
    Smith, V. K., Gifford, K., Ellis, E., Rudowitz, R., Watts, M. O., Marks, C. (2009). The crunch continues: Medicaid spending, coverage, and policy in the midst of a recession [Internet]. Washington (DC): Kaiser Family Foundation. Available from:
  17. 17.
    Children’s Health Insurance Program Reauthorization Act of 2009, Pub. L. No. 111-3, Section 506 (February 4, 2009).Google Scholar
  18. 18.
    Congressional Budget Office. (2008). Geographic variation in health care spending [Internet]. Washington (DC): CBO. Available from:
  19. 19.
    Cooper, R. (2009). States with more health care spending have better-quality health care: lessons about Medicare. Health Affairs, 28(1), w91–w102.PubMedCrossRefGoogle Scholar
  20. 20.
    Fisher, E., Wennberg, D., Stuckel, T., Gottlieb, D., Lucas, F. L., & Pinder, E. (2003). The implications of variation in regional Medicare spending. part 1: The content, quality, and accessibility of care. Annals of Internal Medicine, 138(4), 273–287.PubMedGoogle Scholar
  21. 21.
    Gilmer, T., & Kronick, R. (2011). Differences in the volume of services and in prices drive big variations in spending across U.S. states and among regions. Health Affairs, 30(7), 1316–1324.PubMedCrossRefGoogle Scholar
  22. 22.
    Hadley, J., & Holahan, J. (2002). Variations among states in health insurance coverage and medical expenditures: how much is too much? [Internet] Washington (DC): The Urban Institute. Available from:
  23. 23.
    Landon, B., Schneider, E., Normand, S. L., Scholle, S. H., Pawlson, L. G., & Epstein, A. (2007). Quality of care in Medicaid managed care and commercial health plans. Journals of American Medical Association, 298(14), 1674–1681.CrossRefGoogle Scholar
  24. 24.
    Centers for Medicare & Medicaid Services [Internet]. Baltimore: Centers for Medicare & Medicaid Services; [updated 2011 Jul 18; cited 2011 February 20]. MAX 2006 data validation tables; [about 9 screens]. Available from:
  25. 25.
    Flores, G., & Tomany-Korman, S. C. (2008). The language spoken at home and disparities in medical and dental health, access to care, and use of services in US children. Pediatrics, 121, e1703–e1714.PubMedCrossRefGoogle Scholar
  26. 26.
    Flores, G., Bauchner, H., Feinstein, A. R., & Nguyen, U. S. (1999). The impact of ethnicity, family income, and parental education on children’s health and use of health services. American Journal of Public Health, 89(7), 1066–1071.PubMedCrossRefGoogle Scholar
  27. 27.
    Larson, K., & Halfon, N. (2010). Family income gradients in the health and health care access of US children. Maternal and Child Health Journal, 14(3), 332–342.PubMedCrossRefGoogle Scholar
  28. 28.
    Newacheck, P. W., McManus, M., Fox, H. B., Hung, Y., & Halfon, N. (2000). Access to health care for children with special health care needs. Pediatrics, 105, 760–766.PubMedCrossRefGoogle Scholar
  29. 29.
    Rosenbach, M. L. (1989). The impact of Medicaid on physician use by low-income children. American Journal of Public Health, 79(9), 1220–1226.PubMedCrossRefGoogle Scholar
  30. 30.
    Silver, E. J., & Stein, R. E. K. (2001). Access to care, unmet health needs, and poverty status among children with and without chronic conditions. Academic Pediatric, 1(6), 314–320.Google Scholar
  31. 31.
    Tessler, R. (1980). Birth order, family size, and use of physician services. Health Services Research, 15(1), 55–62.PubMedGoogle Scholar
  32. 32.
    Weinick, R. M., & Krauss, N. A. (2000). Racial/ethnic differences in children’s access to care. American Journal of Public Health, 90, 1771–1774.PubMedCrossRefGoogle Scholar
  33. 33.
    Chang, C., & Steinberg, S. (2009). TennCare timeline: major events and milestones from 1992 to 2009 [Internet]. Memphis: Methodist LeBonheur Center for Healthcare Economics, the University of Memphis. [cited 2011 July 25]. Available from:
  34. 34. [Internet]. Menlo Park (CA): Kaiser Family Foundation; [2010; cited 2011 July 25]. Tennessee: Medicaid managed care; 2010 [about 7 screens]. Available from:
  35. 35.
    Lipson, D., Colby, M., Lake, T., Liu, S., Turchin, S. (2010). Value for the money spent? exploring the relationship between Medicaid costs and quality [Internet]. Washington (DC): Mathematica Policy Research; [cited 2011 February 20]. Available from:
  36. 36.
    Pew Center on the States. (2010). The cost of delay: state dental policies fail one in five children [Internet]. Washington (DC): The Pew Charitable Trusts; [cited 2011 February 20]. Available from:
  37. 37. [Internet]. Menlo Park (CA): Kaiser Family Foundation; [2010; cited 2011 February 20]. Total Medicaid enrollment, FY 2007; [about 9 screens]. Available from:
  38. 38. [Internet]. Menlo Park (CA): Kaiser Family Foundation; [2010; cited 2011 February 20]. Number of children ever enrolled in the Children’s Health Insurance Program (CHIP) 2007; [about 9 screens]. Available from:
  39. 39.
    Maternal and Child Health Bureau [Internet]. Washington (DC): Health Resources and Services Administration; [2007; cited 2011 February 20]. Children’s Health Insurance Program (CHIP) aggregate enrollment statistics: FY 2006; [3 screens]. Available from:
  40. 40.
    Centers for Medicare & Medicaid Services. (2011). CHIPRA initial core set technical specifications manual 2011 [Internet]. Washington (DC): Centers for Medicare & Medicaid Services; [cited 2011 May 2]. Available from:

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Margaret S. Colby
    • 1
  • Debra J. Lipson
    • 1
  • Sarah R. Turchin
    • 2
  1. 1.Mathematica Policy Research, Inc.WashingtonUSA
  2. 2.School of Social WorkColumbia UniversityNew YorkUSA

Personalised recommendations