Provider barriers to specialty medical and oral health care access for children

It is unknown whether public health insurance for children (Medicaid and the Children's Health Insurance Program) ensures access to specialty care that is equal to private insurance. This dissertation used audit methodology, in which trained research assistants posed as parents attempting to schedule appointments, to identify disparities in medical and dental providers' insurance acceptance. Exploratory analyses test for associations between policy-relevant characteristics of medical clinics and discriminatory behavior. From January--May 2010 a stratified, random sample of clinics representing eight medical specialties and dentistry in Cook County, Illinois were called twice by the same person using standardized scripts requesting urgent outpatient appointments. For dental clinics enrolled in the Illinois Medicaid-CHIP dental administrator program (n=41), publicly-insured children had increased odds of being denied any appointment than privately-insured children (odds ratio [OR]:18.2; 95%C1:3.1--infinity), but there were not clinically significant differences in appointment wait-times. For medical specialty clinics (n=273), publicly-insured children had increased odds of being denied appointments than privately-insured children (OR:31.0; 95% confidence interval [CI]:13.0--96.8) and the average wait-time for appointment with public insurance was 22 days longer than private insurance (P=0.005). Of the paired-calls to medical clinics, 57% resulted in discriminatory denials of Medicaid-CHIP. After adjusting for relevant covariates, the odds of a discriminatory denial were 45% lower for clinics affiliated with academic medical centers (OR:0.55; 95%CI:0.31--0.99) and were 5% lower for every one unit increase in the poverty level of clinics' neighborhoods (OR:0.95; 95%CI:0.92--0.98). On average, academic-affiliated clinics scheduled appointments for publicly-insured children with wait-times 40 days longer than privately-insured children (P=0.026) and there was no relationship between a clinic's neighborhood poverty level and wait-times by insurance status (-1.34, P=0.060). Overall, we found disparities in children's access to outpatient specialty medical and oral health care by insurance status. Policy interventions targeting provider participation in public insurance are needed to improve access. Academic medical centers' propensity toward serving publicly-insured patients may make them a candidate for resource allocation to improve access, perhaps contingent on evidence of equitable access in appointment scheduling and wait-times. Investments in increasing the presence of specialty practices in lower-resource communities may help improve access equity.