What Medicaid Expansion Can Tell Us About Child Maltreatment

Luciana C. Assini-Meytin, Ph.D., and Elizabeth Letourneau, Ph.D., co-authored this post.

Can health insurance help protect kids from harm by reducing family violence? That’s a question my colleagues and I are hoping to answer with a series of studies we’re working on about Medicaid expansion.

Increasing access to health care services among low-income adults was the primary goal of dozens of states expanding Medicaid programs in 2014 as part of the U.S. Affordable Care Act. Since then, Medicaid has improved access to and quality of care, as well as the health of the 75 million people it covers.

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There were other benefits as well. Medicaid expansion positively impacted public health by affecting key risk factors for children and their families who reside in low-income communities. Studies show reductions in poverty and crime as a result of Medicaid expansion, which provided insurance to thousands of non-elderly low-income adults, including parents, and increased coverage for more than 700,000 children. Expanding Medicaid also reduced risk factors for child maltreatment, youth violence, and intimate partner violence, including parental financial insecurity, substance use disorders, and untreated mental illness, particularly depression.

When macro-level policies like Medicaid prevent negative health outcomes, they affect change at the largest scale possible and reach millions of people. That’s huge, especially when you compare it to the important but limited reach of individual or family-focused prevention interventions. 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. Child neglect and physical abuse are associated with a host of negative outcomes, including developmental delays, behavioral and emotional issues, and increased risk of developing chronic health conditions, including heart disease, cancer, and mental health, as we wrote in the American Journal of Preventive Medicine.

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.

The differences in the etiology of child maltreatment types lead us to examine the impact of Medicaid expansion on child sexual abuse incidents.

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.”

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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.

1. 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.
2. 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.
3. It’s possible that Medicaid expansion could indirectly affect child sexual abuse in ways that were not detected by our study. Medicaid expansion may protect against child sexual abuse victimization indirectly by influencing broader contexts and risk factors that may enable or impede 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.