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Can Improved Health Care Access Reduce Sexual Violence?

Possible impacts of Medicaid expansion on the prevention of sexual abuse.

The core focus of various projects at the Moore Center is developing prevention programs and evaluating policies that affect child sexual abuse. In the interest of one of our projects, we have been exploring the impact of Medicaid Expansion under the Affordable Care Act (ACA) on financial and crime outcomes as well as various health outcomes.

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Among some of the serious and prevalent public health problems that significantly contribute to the national burden of diseases are three preventable forms of sexual violence: child maltreatment including child sexual abuse, youth violence including sexual abuse perpetration, and intimate partner violence including sexual assault. These forms of violence frequently co-occur within families, and prior victimization substantially increases the risk for subsequent violence perpetration and revictimization. Although there have been sizable declines in all these forms of violence in the U.S. since the 1990s, significant disparities continue to occur. In particular, violence disproportionally affects individuals and families in low-income communities . Even though community crime rates impact everyone residing in that community, families with children are perceived to be at a greater risk. Many experts suggest that improving access to psychiatric medications for common disorders, reducing alcohol use, and increasing job opportunities can contribute to declines in violence. However, these improvements consistently fail to reach many needy and low-income communities.

Broad health care policies have the ability to impact key risk factors for children and their families who reside in low-income communities. One such policy is the Medicaid expansion under the Affordable Care Act (ACA) , which was developed to increase access to health care services and improve health outcomes. The ACA has been a primary issue of debate since its onset. Thirty-seven states and D.C. have expanded Medicaid since January 1, 2014. In addition to the growing evidence of robust increases in insurance coverage among low-income populations and positive effects in health care access and health outcomes , some recent studies have shown reductions in poverty and crime as a result of the expansion. Altogether, expansion under the ACA has provided coverage to thousands of non-elderly low-income adults, including parents, which has resulted in increased Medicaid coverage for over 700,000 children.

More insurance coverage, better access to health care, and reduced medical spending are related with increased access to mental health and substance use treatment, and improved financial stability. Recent studies have linked increases in Medicaid coverage achieved through ACA expansion with well-established risk factors associated with several types of violence. Risk factors including parental depression, parental substance misuse, and family financial problems, are associated with increased risk of child abuse and neglect. For both parents and youth, substance misuse/dependence and depression are associated with youth violence. Additionally, several studies indicate low family income as a risk factor for youth violence. Depression is also associated with both perpetration and victimization of intimate partner violence.

Evaluation of other public policies have indicated positive impacts on child and youth health. Special Nutrition Program for Women, Infants, and Children (WIC) and Food Stamp Program (FSP) was associated with reduced rates of child abuse and neglect . Low-income housing tax credit programs have shown associations with reductions in violent crimes. Programs like the Minnesota Family Investment, that provide financial support to low-income families, show relationships to reduced intimate partner violence. Thus, with increased health insurance coverage there is strong potential for improvement in specific risk factors, eventually leading to the prevention of child abuse and youth violence.

Although there is looming uncertainty about the ACA and whether states will continue to opt in to the Medicaid expansion under the ACA, the implications of such public policies on health outcomes, including child abuse and neglect and youth violence, continue to be of great research interest. Evaluating the impact of such policies on the prevention of violence will contribute to a better understanding of the forces behind declines in violence, especially among disadvantaged populations.