Can health insurance help protect kids from harm by reducing family violence? With a number of research about Medicaid expansion that we are now working on, my colleagues and I hope to provide an answer to that issue.
In 2014, as part of the U.S. Affordable Care Act, dozens of states expanded their Medicaid programs with the primary objective of increasing low-income persons’ access to healthcare services. Since that time, Medicaid has increased healthcare access and quality for the 75 million individuals it serves.
There were other benefits as well. By reducing significant risk factors for children and their families who live in low-income regions, Medicaid expansion has a favorable influence on public health. Studies demonstrate a decrease in poverty and crime as a result of Medicaid expansion, which boosted coverage for more than 700,000 kids and offered insurance to thousands of low-income, non-elderly adults, including parents.
In addition to lowering parental financial insecurity, substance use disorders, and untreated mental illnesses, notably depression, Medicaid expansion also decreased risk factors for teenage violence, intimate partner violence, and child maltreatment.
The broadest possible change is effected and millions of people are affected when macro-level initiatives like Medicaid stop poor health outcomes. That’s a lot, especially when compared to the crucial but constrained reach of preventative programs with an individual or family focus.
This is why my public health colleagues and I are so interested in studying policies. If Medicaid expansion proves to be protective in terms of reducing family violence, that is another potential argument for the dozen states who have not yet expanded Medicaid to do so.
Recent research by our team at the Johns Hopkins Bloomberg School of Public Health and the Moore Center for the Prevention of Child Sexual Abuse examines how Medicaid expansion affected the number of children who experienced maltreatment, including neglect, physical abuse, and sexual abuse. We found some promising news.
Medicaid expansion’s positive on child neglect
In the first study, led by Emma E. McGinty, Ph.D., at the Bloomberg School, we examined the impact of Medicaid expansion on child neglect and physical abuse, the two most common types of reported maltreatment. As we reported in the American Journal of Preventive Medicine, neglect and physical abuse of children are linked to a number of detrimental effects, such as behavioral and emotional problems, developmental delays, and a higher risk of chronic diseases like heart disease, cancer, and mental health.
The study used data from the National Child Abuse and Neglect Data System and expanded on previous studies. We compared rates of neglect and physical abuse among children 17 and younger in 20 states that expanded Medicaid in 2014 to rates in 18 states that did not expand Medicaid by 2018. There were significant reductions in neglect for expansion states, including 13.4%, 14.8%, and 16% for children aged 0-5, 6-12, and 13-17, respectively.
There were no statistically significant associations between Medicaid expansion and child physical abuse, although trends were lower in expansion states than in non-expansion states. “Relative to physical abuse, the etiology of neglect is more closely tied to poverty and therefore may be more sensitive to policies that reduce family financial hardship,” we write.
We investigate the effect of Medicaid expansion on instances of child sexual abuse in light of the variations in the etiologies of various forms of child maltreatment.
Investigating connections to child sexual abuse
In the second study, led by Luciana Assini-Meytin, Ph.D. of the Moore Center and published in the journal Child Maltreatment, researchers used NCANDS data to examine for the first time the impact of Medicaid expansion on incidence of child sexual abuse.
Child sexual abuse is reported less often than neglect or physical abuse and cases have declined approximately 62% between 1992 and 2018, the team noted. “However, despite the observed significant decline in CSA substantiated cases, the most recent estimates suggest that many children, including 1 in 5 girls and 1 in 10 boys will be sexually victimized before age 18.”
We speculated we might see an initial increase in reported child sexual abuse incidents in states that expanded Medicaid, because parents of children on Medicaid would be seeking health care more frequently and health care professionals might therefore identify more reportable cases. Instead, we found no statistically significant association between Medicaid expansion and reported child sexual abuse.
Potential reasons for our findings
There are a number of potential reasons why we did not see a decrease in reports of child sexual abuse.
- Child sexual abuse is different than other forms of child maltreatment, which are more often perpetrated by parents and guardians. Among the child sexual abuse cases identified in the NCANDS data, only 5% of parents and 16% of guardians were indicated as perpetrators, compared to child neglect where 82% and 73% of perpetrators were indicated as parents and guardians.
- While some risk factors (e.g., parental substance use problems) are shared across types of child maltreatment, some are unique to child sexual abuse (e.g., sexual attraction to children). We need to learn more about shared and unique risk and protective factors. We can’t assume that policies that work to decrease some forms of child maltreatment will affect all forms of maltreatment equally.
- Medicaid expansion might indirectly impact child sexual abuse in ways that our analysis did not pick up on. By changing broader settings and risk factors that may facilitate or hinder victimization, Medicaid expansion may indirectly protect against child sexual abuse victimization. For example, “Improved family finances may mitigate the need for parents to hold multiple jobs, which increases parental supervision and deters sexual abuse against the child,” we write. Such impacts might require longer follow-up to detect.
Our next steps
Now we are studying the impact of Medicaid expansion on youth violence and on intimate partner violence types of family violence we hypothesize can be impacted by financial instability, depression, and parental substance abuse, risk factors reduced by Medicaid expansion. We are at the very beginning of understanding how macro-level policies impact child sexual abuse and other forms of child maltreatment, and there’s still a lot we need to learn. We hope that through this research we can identify policies that help protect children and prevent them from ever being harmed.
