Physical and behavioral health of Medicaid children in two Southern states.

Objectives: As the primary insurer of children in the United States, Medicaid covers at least one in four US children. Information on the health and behavioral health needs of this group of children is critical to plan, deliver, and monitor services accordingly.

Methods: Parent interview data from a representative sample of Medicaid children in two Southern states were used to generate information from standardized questionnaires on physical health status, chronic illnesses, physical functioning, emotional and behavioral symptoms, and psychosocial functioning.

Results: The levels of physical and behavioral health and co-occurring problems were higher than other estimates available on the general population.

Conclusions: The high levels of health problems among Medicaid-enrolled children need attention in the current struggles over Medicaid reform. Support for improving screening, referral, and integration of services is discussed, as well as the importance of monitoring service system performance in this era of managed care.

Key Words: adolescent, child, health, Medicaid, mental health, population characteristics

**********

The Medicaid Program will celebrate its 40th anniversary in 2005. Created as Title XIX of the Social Security Act in 1965, Medicaid is the jointly funded federal-state program for financing health services for low-income and disability groups. (1) In 2000, there were 33.7 million people on Medicaid in the United States. More than half of these were children, representing one in five US children, and that proportion is growing. (2) The health care needs of children in families with limited economic resources are of special public health concern and have been for many years, largely due to higher prevalence rates of health and behavioral problems among the poor. (3) The number of children living in poverty continues to increase, and studies of poor children have long suggested that their health status is more in jeopardy than that of the general public. (4)

The importance of the Medicaid program for America's children and families continues, with Medicaid providing some buffer for the loss of employer health care coverage as economic conditions deteriorated over the past 3 years. (5) More than one of every four American children is a Medicaid enrollee. (6) As state tax revenues have also decreased during the same time period, states are looking for ways to cut spending on their Medicaid programs, with all 50 states and the District of Columbia planning cost containment strategies for the 2004 programs. (7)

The costs and benefits of policy changes in state Medicaid programs depend critically on the health status of enrollees. In a capitated system, if new enrollees are sicker and more expensive to treat than anticipated, the managed care firms will earn less profit. Similarly, if states disenroll clients, differences in health status between remaining and leaving members will affect health plan profitability. Although it might seem from a state's perspective that cutting costs is as simple as restricting enrollment, some costs may not emerge until future time periods. For example, disruptions in Medicaid enrollment among schizophrenic patients ultimately increased treatment costs for the Medicaid system due to deterioration in the patients' health status. (8) Raising the expected cost of treating patients will lead to higher capitation rates.

Yet many changes to the Medicaid program proceed without systematic data on health and behavioral health status measures. More than half of Medicaid beneficiaries have been shifted to managed care, (9) and age and income expansions for children, in addition to the State Children's Health Insurance Plan, (10) have placed significant burdens on state budgets. (11)

This study documents the physical and behavioral health problems of children in two Southern states, Tennessee and Mississippi, where Medicaid covers 42 and 21% of children and adolescents, respectively. Tennessee was one of the leaders in both the transition to managed care and enrollment expansion as a result of its TennCare physical health (January 1994) and behavioral health (July 1996) programs, (12) and enrollment expansion to include children who were uninsured or uninsurable. Mississippi had significant growth in enrollment but did not implement managed care, apart from some limited primary care case management demonstrations. (13) Both states are grappling with cost containment concerns, making policy decisions about benefits and beneficiaries that will influence children's access to services. (14)

Data Sources and Methods

Sample

The Vanderbilt University Institutional Review Board approved this study. Recruitment for the study proceeded in three steps. First, we identified 310,366 youths in Tennessee and 132,733 in Mississippi who were categorically eligible and enrolled in Medicaid during a 12-month period and who would be ages 4 to 17 years of age at the time of the interviews. We selected potential respondents, based on observable characteristics (age, sex, race, past service use, and degree of urbanization), across each state. Next, a two-stage recruitment process was used because of confidentiality concerns expressed by the state Medicaid bureaus. In the first stage, parents/guardians of the children (n = 5,205 in Tennessee, n = 5,817 in Mississippi) were contacted by mail originating from a state agency on its letterhead until 1,000 respondents consented to participate (500 in each state) through return of a postcard or a call to a toll-free number. The primary difference between interviewees and nonrespondents were that Tennesseans with past service use and nonwhite (primarily black) respondents in both states were more likely to participate in the study. (15) However, the use of sampling weights that account for variation in service use and race control for these discrepancies.

In the second stage, interviewers obtained written consent to participate during an in-person visit with those who had consented to be contacted. No one who consented to be contacted refused to be interviewed, but some were excluded because they no longer had Medicaid eligibility. The result was a net yield of 473 Tennessee interviews and 490 Mississippi interviews. Although this yield is low by traditional survey research standards, it is comparable to other mail-based recruitment strategies with Medicaid enrollees (16) and demonstrates that policy researchers can derive beneficiary-focused information for monitoring and research. We also created poststratified sampling weights that accounted for nonresponse as well as the sampling strata, based on Medicaid claims/encounter and enrollment data for each state, (17) a standard technique used by major national surveys like the National Health Interview Survey (NHIS) and Survey of Income and Program Participation. Thus, this group of 963 children functions as statewide representative samples of Medicaid children in two states, yielding important findings that generalize to the population of Medicaid-enrolled children in Mississippi and Tennessee. (18)

Table 1 presents the weighted distribution of survey respondents on sex and age, by racial group. In Tennessee, this child Medicaid population is slightly more than half (56%) white, whereas in Mississippi, three quarters (77%) of the Medicaid children are black. In both states, proportions of boys and girls are similar, with black children more likely to be male and white children, female. As can be seen in the age distribution shown in Table 1, white children in both states are more likely to be in the younger age group (4 to 8 years), whereas black children were more evenly distributed among the age groups. It should be noted that in both states, a very small proportion of the children ages 4 to 17 enrolled in Medicaid during this time period were of other races (as indicated in the Medicaid enrollment files): in Tennessee, 2.1%, and in Mississippi, 3.2% of the enrolled children were Hispanic, Asian-American, or other racial/ethnic categories. These children are not reflected in the tables, since the proportions are so small that generalization was of concern (estimates were unstable).

Measures

In-person interviews were conducted with parent/guardians at the participants' homes or a place of their determination and covered topics related to the child's physical and emotional well-being as well as information about the child's family and living conditions. Interviewers were trained to administer the structured interview in a standardized manner by university research staff, and interviews were tape-recorded and checked for quality of administration and scoring.

Two measures of physical health from the Child Health Questionnaire (CHQ) (19) were used: child's Global Health Status (assessment of the child's health as excellent, very good, good, fair, or poor; same question as used in the NHIS (20)); and the Physical Functioning Scale (presence and extent of physical limitations in self-care, mobility, and activities varying in strenuousness). In addition to the ratings of global health, the CHQ produces standardized scale scores, ranging from 0 to 100, with higher scores indicating increased functioning and fewer limitations. Other items used in the analyses included parent information on any chronic illnesses and handicaps. Parents reported whether their children had ever received formal diagnoses of chronic health conditions, and, if yes, the types of conditions.

Two behavioral health scales were used to determine whether or not the children met federal criteria (21) for serious emotional disorder (SED) (ie, diagnosis of a mental health problem and impairment in psychosocial functioning). To measure mental health problems, the Child Behavior Checklist (CBCL), (22) a common measure of mental health symptoms, was used. The cut-point for the clinical range on the CBCL was used to define the presence of serious mental health problems and is based on T scores normed on a clinical population, with higher scores indicating more clinical symptoms. Many studies have shown that CBCL subscale scores correlate with diagnoses. (23) The Columbia Impairment Scale (CIS) (24) measured psychosocial functioning, and the clinical cut-point was used to designate impaired functioning. (25) The CIS has been demonstrated to be a reliable and valid measure of psychosocial impairment and correlates highly with the clinician-determined scores of the Children's Global Assessment Scale. (26)

Physical and Behavioral Health Status of Medicaid Children

Physical health

Results for the statewide representative samples on physical health measures are shown in Table 2. About three fifths of children in both states were rated as being in excellent or very good health. This is far below estimates for the general population from the NHIS (27) but comparable to estimates for children in poverty.

One quarter or more of the Medicaid children were reported to have limitations due to physical health problems. Children's mean standardized scores on the CHQ Physical Functioning Scale ranged from 80.4 to 87.6. These are greater levels of activity limitation than have been reported for other groups of children. Poor children previously have been documented as having more problems due to chronic health conditions, (28) with 11% reporting at least some activity limitation in the NHIS. To date, only isolated reports from independent studies have comparable information available using the Physical Functioning Scale, and all scored in better health than the Tennessee and Mississippi children in this study: For example, Landgraf and Abetz (29) found a mean score of 88.8 for a sample of primarily black school-aged children; another study (30) reported a mean score of 94.2 for children with one or more chronic conditions; and Waters et al (31) reported a mean of 94.6.

From 25 to 41% of the Medicaid children reported at least one chronic health condition, comparable to the 31% rate in the 1992 to 1994 NHIS. (32) The most frequent chronic health condition mentioned in both states was asthma, reported for more than half of the black Medicaid children with chronic conditions in either state. This is consistent with prior research on asthma in the Medicaid population. (33) The next most common conditions were allergies, speech disorders, and vision problems. This corresponds with another study in which Medicaid children were found to have higher rates of chronic conditions than children insured through an employer group. (34)

Behavioral health

Table 3 shows the proportion of TennCare and Medicaid enrollees with behavioral health problems. Overall, approximately one quarter (22 to 26%) of the Medicaid child population met the two-part criteria for having an SED, with an additional 9 to 34% having significant emotional or behavioral problems on either the CBCL or CIS, but not both.

Recent studies have highlighted the prevalence of child and adolescent mental health problems, (35) and the level of SED found in this study is within the range typically reported in the literature. Prevalence estimates of childhood symptomatology in broad community studies have varied widely, from 1 to 51%, with a mean of 15.8%. (36) When researchers measure both symptoms and psychosocial impairment, the rate drops to 12.3% or less. (37) However, children in poverty have been found to have double the rate of SED, (38) and because the Medicaid population is primarily composed of poor children or those with disabilities, higher rates of behavioral problems are to be expected. The prevalence rates in this sample are similar to those found in a study of children in state custody in Tennessee (31%) (39) that used methods similar to this study.

Co-occurring physical and behavioral health problems

In both states, from one third to one half of children with SED reported a co-occurring chronic health condition (see Table 3). Children with SED were significantly more likely to report a chronic health condition than other TennCare and Mississippi Medicaid children. The one exception was with white Medicaid children in Mississippi, where those without SED had higher rates of chronic health conditions. This group of children tended to be younger (see Table 1) and had higher levels of chronic health conditions and physical limitations (see Table 2).

No other national estimates with comparable information on co-occurring physical and mental health problems are available. However, the relation between SED and the physical health variables among this population of children was examined in more detail in another study, (40) which found that children with SED had worse health status, more limitations due to physical health problems, and more chronic illnesses even after controlling for demographic characteristics and chronic illnesses.

Limitations of the Current Study

The 50 states' Medicaid programs vary considerably in terms of beneficiary eligibility and program structure, and our study focuses only on children in two Southern states. However, we limited our sample to children enrolled in the Medicaid categorically eligible programs that apply in all states. Identifying and meeting the health needs of Medicaid beneficiaries within current fiscal constraints are national issues, and policy planning could benefit from additional studies that assess population level physical and behavioral health problems among Medicaid enrollees, particularly children and adolescents.

Although our data and the statistical weighting techniques used allow us to adjust for a range of systematic differences between the interview sample and the full population, (41) study participants may still differ in some unmeasured ways. The statistical weighting technique took into account age, race, sex, urban-rural location, and history of service use. However, it may be that the sample actually differed from the full population in unmeasured ways. For example, children may have differed in their health status, and our demographic and service history controls used to construct the sampling weights only imperfectly capture this variation. Thus, our sample may have recruited individuals with poorer health status. However, comparisons of our results to estimates on similarly disadvantaged children suggest our estimates are not out of line.

Also, relying on parent reports of chronic illnesses tends to produce higher prevalence estimates than studies that use clinical examinations, due largely to parents' overreporting of conditions that have little impact on children's functioning. (42) On the other hand, unlike the NHIS, which cues parents with a list of conditions, caregivers in this study named their children's chronic conditions without reference to a list, which might lead to an understatement of problems. It is hard to estimate how these methods may have influenced the respondents' answers.

Conclusion

This study offers the first data about physical and behavioral health status among statewide populations of children enrolled in Medicaid programs anywhere in the United States. The data from these two statewide representative samples demonstrated high levels of physical and behavioral health problems among Medicaid children and adolescents, as well as high rates of co-occurring physical and mental health problems. Current federal policies that focus on promoting healthy lifestyles (43) and identifying and treating mental health and substance abuse early (44) emphasize the need for this type of information for improving practice, service delivery, and policy planning.

Medicaid's Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program (45) nominally provides a method for addressing these problems. Preventive and periodic screening should not only identify acute and chronic physical health problems and associated activity limitations but also include behavioral health issues as is mandated through the Medicaid program. Given the high rates of emotional and behavioral health problems in this population, physicians should expect to identify mental health problems and know their local resources for referral. Similarly, mental health professionals must recognize the need to identify and obtain treatment for co-occurring physical health problems and should routinely refer their clients for preventive screens as well as follow-up with their primary care providers. EPSDT makes preventive and period screens for health, including behavioral health, available for all Medicaid enrollees under the age of 21 years; however, implementation of the EPSDT program varies widely across states. (46)

These findings also indicate that coordination of services between physicians and mental health providers is needed at the practice and policy levels. Best practice guidelines call for communication and coordination among physical and behavioral health providers (eg, American Academy of Pediatrics (47)), and guiding principles for children's services emphasize the importance of access to and coordination among a full array of services addressing the comprehensive needs of children. (48) Coordinated services that integrate both pediatric and mental health services might be cost-effective in improving the long-term prognosis and medical course for children whose physical conditions contribute to poor mental health (49) and vice versa. Coordination between physical and behavioral health providers and authorization systems has been a concern in Medicaid managed care programs, particularly for "carve-out" systems. (50) Whether carved out or not, some form of interface between the systems is necessary, and research and policy should focus on the factors that improve this interface. (51) Furthermore, with a population reporting such high levels of chronic health problems and activity limitations due to physical health problems, access to specialty providers becomes an important issue.

The use of managed care to provide health care to Medicaid beneficiaries has become increasingly widespread, with national enrollment rates continuing to grow. (52) Managed care is designed to improve access and reduce costs by eliminating inappropriate and unnecessary services and relying more heavily on primary care and coordination of care. (53) Eliminating inappropriate and unnecessary care requires examination of the actual needs and service use of Medicaid enrollees. However, monitoring for health status or clinical outcomes has not been widely implemented, monitoring of service use has been slow to be implemented, and efforts to benchmark performance are hard to find. (54) Access to physical and behavioral health care and managed care contractor compliance with other performance indicators should be closely monitored by state Medicaid agencies to evaluate whether the levels of physical and behavioral health needs in this population are being addressed. As states implement performance standards for service utilization, it would be wise to consider additional measurement of physical and behavioral health problems to ensure that the health needs in this population are being addressed.

Table 1. Weighted sample characteristics by state and race (a)

                   Tennessee         Mississippi
                 Black    White    Black    White
Characteristic   (41.6%)  (56.3%)  (77.4%)  (19.4%)

Sex
  Female         45.1%    51.4%    45.7%    55.4%
  Male           54.9%    48.6%    54.3%    44.6%
Age
  4-8 yr         32.8%    44.9%    35.4%    52.9%
  Ages 9-12 yr   32.0%    25.0%    34.1%    11.1%
  Ages 13-17 yr  35.2%    30.1%    30.5%    36.0%

(a) These findings reflect the weighted sample representing 310.366
Tennessee children and 132,733 Mississippi children. Comparisons are not
made between Tennessee and Mississippi or between racial groups in this
or other tables because the focus is on describing these populations for
public health policy planning purposes.

Table 2. Child global health status, chronic conditions, and physical
functioning by state and race: Statewide population estimates (a)

                                        Tennessee
Characteristic                     Black         White

Global health status
  Excellent or very good           59.7%         67.1%
  Good                             16.2%         24.7%
  Fair or poor                     24.1%          8.2%
Mean global health score (b) (SD)   2.40 (0.11)   2.03 (0.06)
Mean global health standardized    71.12 (2.73)  79.93 (1.32)
    score (c) (SD)
Any physical limitation            27.7%         26.1%
Mean physical functioning          80.42 (2.81)  85.73 (1.49)
    standardized score (SD) (c)
Any chronic health condition       35.7%         30.1%
Most frequent chronic health
    conditions (d)
  Asthma                           58.2%         35.5%
  Severe allergies                  9.7%         28.6%
  Speech disorders                  1.6%         26.4%
  Vision/blindness                  1.3%         19.3%

                                       Mississippi
Characteristic                     Black         White

Global health status
  Excellent or very good           55.1%         69.5%
  Good                             25.2%          8.5%
  Fair or poor                     19.7%         22.0%
Mean global health score (b) (SD)   2.45 (0.06)   2.45 (0.10)
Mean global health standardized    70.76 (1.43)  67.22 (2.63)
    score (c) (SD)
Any physical limitation            24.2%         37.6%
Mean physical functioning          87.64 (1.25)  87.55 (2.19)
    standardized score (SD) (c)
Any chronic health condition       25.4%         40.8%
Most frequent chronic health
    conditions (d)
  Asthma                           63.8%         38.7%
  Severe allergies                 23.5%         50.2%
  Speech disorders                  8.0%         47.3%
  Vision/blindness                 14.2%         13.8%

(a) Comparisons are not made between Tennessee and Mississippi or
between racial groups in this or other tables because the focus is on
describing these populations for public health policy planning purposes.
(b) Scores from 1 (excellent) to 5 (poor).
(c) Scores from 0 to 100, with higher scores indicating increased
functioning and fewer limitations.
(d) Proportion of children with at least one chronic health condition
(proportion of overall population).

Table 3. Behavioral health status by state and race: Statewide
population estimates and chronic health conditions by SED Status (a,b)

                                               Tennessee
Characteristic                            Black         White

Percent with mental health problems
  SED                                     26.1%         26.2%
  Impaired functioning or symptomatology  21.7%         21.1%
  No problems                             52.2%         52.7%
Mean CBCL score (SD)                      56.52 (1.35)  56.67 (0.69)
Mean CIS score (SD)                       14.39 (1.18)  14.39 (0.57)
Percent with chronic health conditions
  Children with SED (b)                   55.2%         41.1%
  Children with no SED                    27.2%         24.8%
Mean number of chronic health conditions
    (SD)
  Children with SED (b)                    0.56 (0.14)   0.69 (0.09)
  Children with no SED                     0.25 (0.06)   0.56 (0.12)

                                              Mississippi
Characteristic                            Black         White

Percent with mental health problems
  SED                                     22.0%         24.8%
  Impaired functioning or symptomatology   9.3%         33.7%
  No problems                             68.7%         41.5%
Mean CBCL score (SD)                      52.00 (0.89)  57.00 (1.50)
Mean CIS score (SD)                       11.38 (0.60)  13.59 (0.97)
Percent with chronic health conditions
  Children with SED (b)                   49.8%         35.4%
  Children with no SED                    17.8%         42.7%
Mean number of chronic health conditions
    (SD)
  Children with SED (b)                    1.33 (0.16)   0.75 (0.21)
  Children with no SED                     0.20 (0.04)   1.62 (0.34)

(a) SED, serious emotional disorder; CBCL, Child Behavior Checklist;
CIS, Columbia Impairment Scale.
(b) [chi square] tests of difference between children with and without
SED were significant at P < 0.0001 for both states.

Acknowledgments

The authors acknowledge the contributions of the Impact Study research team in the collection and analysis of data for this manuscript: Denine Northrup, PhD, Lisa Dordal, Celeste G. Simpkins, and William Renfrew, MA. The collaboration and data collection efforts of the Mississippi Families as Allies, Tennessee Commission on Children and Youth, and Tennessee Voices for Children were also critical. The reviews of E. Michael Foster, PhD, Ana Maria Brannan, PhD, and Kelly Taylor-Richardson, MSW, are appreciated. The authors also thank all of the families who participated in the study and shared their time and information about their children to make this study possible.

Accepted October 5, 2004.

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42. See Newacheck & Halfon (1998) in note 3 above.

43. United States Department of Health and Human Services (USDHHS): Healthy people 2010: Understanding and improving health (2nd edition). Washington, US Government Printing Office, November 2000. [http://www.healthypeople.gov].

44. See New Freedom Commission on Mental Health (2003) in note 35 above.

45. Center for Medicaid and Medicaid Services: Medicaid and EPSDT, undated. [http://cms.hhs.gov/medicaid/epsdt/default.asp]. Kaiser Commission on Medicaid and the Uninsured: The Medicaid Program at a Glance. January 2001. [http://www.kff.org/medicaid/2004b-index.cfm].

46. Government Accounting Office: Medicaid: Stronger Efforts Needed to Ensure Children's Access to Health Screening Services (GAO Pub. No. GAO-01-749). Washington, Author, 2001.

47. American Academy of Pediatrics: Insurance coverage of mental health and substance abuse services for children and adolescents: a consensus statement. Pediatrics 2000;106:860-862.

48. Stroul BA. Issue Brief: System of Care: A Framework for System Reform in Children's Mental Health. Washington, CASSP Technical Assistance Center at Georgetown University, 2002.

49. Walders N, Drotar D. Integrating health and mental health services in the care of children and adolescents with chronic health conditions: assumptions, challenges, and opportunities. Children's Services: Social Policy. Research, and Practice 1999;2:117-138.

50. Fox HB, Wicks LB, Newacheck PW. Health maintenance organizations and children with special health needs: a suitable match? Am J Dis Child 1993;147:546-552. Bazelon Center for Mental Health Law. Effective Public Management of Mental Health Care: Views from States on Medicaid Reforms that Enhance Service Integration and Accountability. Washington, Author, May 2000. [www.milbank.org/bazelon].

51. Kagan SL, Golub SA, Goffin SG, et al. Toward Systemic Reform: Service Integration for Young Children and Their Families. Falls Church, VA, National Center for Service Integration, 1995.

52. Centers for Medicare and Medicaid Services: 2002 Medicaid Managed Care Enrollment Report. Washington, Author, 2003 [http://www.cms.gov/medicaid/managedcare/trends02.pdf].

53. Deal LW, Shiono PH. Medicaid managed care and children: an overview. The Future of Children 1998;8:93-105.

54. Perlman SB, Nechasek SL, Dougherty RH. Children's mental health benchmarking: Progress and potential. Behavioral Healthcare Tomorrow 2001;10:14, 36-37. Saunders RC, Heflinger CA. Access to and patterns of use of behavioral health services among children and adolescents in TennCare. Psychiatric Services 2003;54:1364-1371.

RELATED ARTICLE: Key Points

* Medicaid children have high levels of physical and behavioral health problems that need identification and treatment.

* Approximately one of every three Medicaid children reported a chronic health condition, with one of every four having some type of physical limitation as a result.

* One quarter of the Medicaid children had emotional or behavioral health problems at levels severe enough to be classified as having a serious emotional disorder.

* Many children had co-occurring physical and behavioral health problems, with children with serious emotional disorders more likely to have physical health problems than those with less severe behavioral problems.

* To promote physical and behavioral health, early identification, treatment, and coordination are critical--between physicians and mental health professionals as well as at the policy level.

* State Medicaid agencies should monitor access to physical and behavioral health services and managed care contractor compliance with performance indicators.

Craig Anne Heflinger, PHD, and Robert C. Saunders, MPP 

From the Department of Human and Organizational Development, Peabody College, Vanderbilt University, Nashville, TN.

Supported by grants from the Substance Abuse and Mental Health Services Administration, Centers for Substance Abuse Prevention, Mental Health Services, and Substance Abuse Treatment (UR7 TI11304 and KD1 TI112328).

Reprint requests to Dr. C.A. Heflinger, Peabody College #90, 230 Appleton Way, Nashville, TN 37203. Email: [e-mail]