Medicaid and Children's Access to Care

To the Editor: Dr Newacheck and colleagues¹ report that poor children covered by Medicaid have greater access to care and greater use of services than poor children without insurance, and that poor children covered by Medicaid have less access to care and less use than nonpoor children with private insurance. Based on these findings, Newacheck and colleagues conclude that there are structural problems (low reimbursement levels) in the Medicaid program that prevent an equalization of access and use between poor and nonpoor children. This conclusion is not justifiable. The comparison of access and use between poor children covered by Medicaid and nonpoor children covered by private insurance does not identify differences in access and use due to differences in insurance coverage, but rather differences in access and use due to differences in insurance coverage and income. Thus, it is inappropriate to draw inferences about the effectiveness of Medicaid coverage based on this comparison since it is confounded by income. A better research design would have been to compare access and use between poor children covered by Medicaid and poor children covered by private insurance.