Preconception subsidized insurance: Prenatal care and birth outcomes by race/ethnicity

Low‐income pregnant women have been Medicaid eligible since the 1980s, but the Affordable Care Act (ACA)'s expansion of Medicaid to women preconception has the potential to improve pregnancy and birth outcomes by removing delays in Medicaid enrollment. More substantially, the ACA expanded subsidized nongroup maternity coverage. Pre‐ACA, nongroup health insurance had generally excluded maternity coverage and was prohibitively expensive for low‐income individuals, but the ACA's creation of the Marketplace made maternity coverage mandatory and provides income‐based subsidies. I use a simulated eligibility approach to measure how these two aspects of the ACA impacted pregnancy and birth outcomes for first‐time mothers, paying special attention to racial‐ethnic differences. I find expanding Medicaid to women prior to pregnancy significantly improves the share of women with a prenatal care visit in the first trimester for non‐Hispanic Whites and Blacks. Expansions in non‐Medicaid subsidized insurance, such as Marketplace insurance, significantly reduce the share of births paid by Medicaid and increased breastfeeding across all racial and ethnic groups. Neither type of subsidized insurance had significant, robust impacts on birth outcomes.     

Development of the Child's Challenging Behaviour Scale (CCBS) for mothers of school‐aged children with disabilities

Background Caring for a child with a disability can be especially difficult when the child exhibits challenging behaviours. Childhood disability often calls for the mother to be conscientious, capable and organized to meet the child's health and developmental needs. Mothers are known to feel particularly stressed when their child also behaves in ways that are difficult to manage. In these circumstances maternal mental health may be compromised and mothers therefore need more support. The Child's Challenging Behaviour Scale (CCBS) is an 11‐item scale that measures a mother's report of challenging behaviours exhibited by their child with disability, that are associated with compromised maternal mental health and caregiving difficulties. This paper describes the initial development and psychometric evaluation of the CCBS. Methods A mixed methodology instrument design model was used to develop the CCBS. A qualitative study generated items, and quantitative data were collected from 152 mothers of a child with a disability. Results The CCBS showed excellent internal consistency (Cronbach's alpha = 0.89) and factor analysis supported its unidimensionality. Construct validity was supported by correlations with the PedsQL Psychosocial Health Summary Score (rho =?0.51) and cooperation taking medication (rho = 0.40). There were significant differences in CCBS scores between groups of children with and without either autism or psychiatric conditions. The CCBS showed moderate correlations with self‐reported health status; the mother's sense of empowerment (rho =?0.44); and family cohesion (rho =?0.30). Mothers with a mental health condition recorded significantly higher CCBS scores. Conclusions The CCBS is a brief, psychometrically sound instrument that provides clinicians with a new tool that measures a mother's rating of their child's behaviours that are challenging and associated with reduced maternal well‐being. The CCBS assists professionals to identify mothers and family situations who may be in need of more support and interventions.     

Welfare reform and health insurance coverage of low-income families

We study whether welfare reform adversely affected the health insurance coverage of low-educated single mothers and their children. Specifically, we investigate whether changes in the welfare caseload during the 1990s were associated with changes in Medicaid participation, private insurance coverage, and the number of uninsured among single mothers and their children. Estimates suggest that between 1996 and 1999, the 42% decrease in the welfare caseload was associated with the following changes in insurance coverage among low-educated, single mothers: a 7-9% decrease in Medicaid coverage; an increase in employer-sponsored, private insurance coverage of 6%; and a 2-9% increase in the proportion uninsured. Among children of low-educated, single mothers, effects were somewhat smaller. Since welfare policy was responsible for only part (e.g. one-third) of the decline in the caseload, welfare reform per se had significantly smaller effects on the health insurance status of low-income families. However, we found limited evidence that changes in the caseload due to state and federal welfare policy had fewer adverse consequences on insurance status than changes in the caseload due to other factors. This implies even smaller effects of welfare reform.     

Credit where it is due: Investigating pathways from earned income tax credit expansion to maternal mental health

While earned income tax credit (EITC) expansions are typically associated with improvements in maternal mental health, little is known about the mechanisms through which the program affects this outcome. The EITC could primarily affect mental health through changes in family financial resources, changes in labor supply or changes in health insurance coverage of participants. We attempt to disentangle these mechanisms by assessing the effects of state and federal EITC expansion on mental health, employment, and health insurance by maternal marital status. We find that federal EITC expansions are associated with improved self‐reported mental health for all mothers and large positive effects on employment for unmarried mothers. State EITC expansions are associated with improvements in mental health for married mothers only and have no effect on employment for married or unmarried mothers. Overall and for most subgroups of mothers, we find little association between EITC expansions and changes in health insurance coverage. These findings suggest that while EITC expansions improved mental health for unmarried mothers through a combination of the credit and employment effects, for married mothers, improved mental health is driven through the direct credit alone.     

Native Hawaiian Birth Weight and Infant Mortality: Is Birth in Hawai'i Protective?

PURPOSE OF THE PAPER: This study provides baseline information on the characteristics of Native Hawaiian mothers and the health status of their infants, comparing residents of Hawaii with those of the continental U.S. The impact of Hawaii residence on low birth weight and infant mortality among Native Hawaiians is assessed. SUMMARY OF METHODS UTILIZED: Data from the National Center for Health Statistics 1983­1987 Linked U.S. Live Birth and Infant Death file were used to examine parental characteristics, prenatal care use and infant outcomes using chi­square and logistic regression procedures. PRINCIPAL FINDINGS: Despite a higher sociodemographic risk profile among Hawaii resident mothers, preterm birth, low and very low birth weight percentages were similar. Continental infants had significantly highter percentages of very pre­term birth and macrosomia. Mortality rates in both the neonatal and post­neonatal periods, and for SIDS and perinatal causes were elevated among continental infants. Hawaii residence had a borderline protective effect on infant mortality, wehn sociodemographic and prenatal care differences were controlled. CONCLUSIONS: This study suggests a possibly protective effect of Hawaii residence on the health of Native Hawaiian infants during the period of following employer­mandated health insurance coverage but before the initiation of "gap­group" coverage and the Native Hawaiian Health Care Systems in Hawaii. RELEVANCE TO ASIAN PACIFIC ISLANDER AMERICAN POPULATIONS. This is the first report documenting the sociodemographic and health status of the growing number of Native Hawaiian mothers and their infants residing outside of Hawaii. Expanded health insurance coverage and culturally appropriate and accessible health care may contribute to improved infant health status in Hawaii. Their absence, along with possible barriers of sociocultural isolation, may account for the poorer than expected outcomes of continental infants and predict a widening gap between them and their counterparts in Hawaii. A follow­up study of the health status of Native Hawaiian mothers and infants, and their access to appropriate care in Hawaii and thei continental U.S. is recommended.     

Parental health and child schooling

This paper provides new empirical evidence on the impact of parental health shocks on investments in children's education using detailed longitudinal data from Bosnia and Herzegovina. Our study controls for individual unobserved heterogeneity by using child fixed effects, and it accounts for potential misreporting of self-reported health by employing several, more precise, health indicators. Results show that co-living children of ill mothers, but not of ill fathers, are significantly less likely to be enrolled in education at ages 15–24. Moreover, there is some evidence that mother's negative health shocks are likely to raise the employment probability of children due to the need to cover higher health expenditures.     

Take-Up of Public Insurance and Crowd-Out of Private Insurance under Recent CHIP Expansions to Higher Income Children

Objective

To analyze the effects of states'' expansions of Children''s Health Insurance Program (CHIP) eligibility to children in higher income families on health insurance coverage outcomes.

Data Sources

2002–2009 Current Population Survey linked to multiple secondary data sources.

Study Design

Instrumental variables estimation of linear probability models. Outcomes are whether the child had any public insurance, any private insurance, or no insurance coverage during the year.

Principal Findings

Among children in families with incomes between two and four times the federal poverty line (FPL), four enrolled in CHIP for every 100 who became eligible. Roughly half of the newly eligible children who took up public insurance were previously uninsured. The upper bound “crowd-out” rate was estimated to be 46 percent.

Conclusions

The CHIP expansions to children in higher income families were associated with limited uptake of public coverage. Our results additionally suggest that there was crowd-out of private insurance coverage.     

What Explains the Decline in Neonatal Mortality in India in the Last Three Decades? Evidence from Three Rounds of NFHS Surveys

Identifying the factors that have contributed to recent declines in neonatal mortality in India may help determine which policies and programs are most likely to facilitate further reductions. We use data from the 1992–93, 2005–06, and 2015–16 National Family Health Surveys (NFHS) to examine trends in neonatal mortality in India. We use multivariable decomposition to estimate the contribution of different factors to the change in neonatal mortality in India in the last three decades. When limited to most recent births in the 1–47 months preceding the surveys, 70 percent of the decline in neonatal mortality from 1992–2016 is due to changes in utilization of maternal‐ and child‐care program factors and distribution of household, mother's, and child's characteristics. Improvement in “mother's schooling” and increase in utilization of “at least two tetanus toxoid injections” contributed the most followed by the increase in use of “at least three antenatal‐care visits” and “clean fuel for cooking.” The change in distribution of “birth order” also contributed significantly to the decline in neonatal mortality. Change in the benefits of “access to improved water,” “delivery in a medical facility,” and “mother's schooling” has led to a decline of 3 points, 2 points, and 1 point, respectively. More investments in maternal‐ and child‐health programs (including family planning) and providing clean fuel for cooking are likely to pay higher dividends.     

Breast‐feeding patterns in Saudi Arabia

A survey was conducted on 1019 mothers in 79 primary health care centers in Saudi Arabia to determine the patterns of breast‐feeding. A large percentage of the mothers (98%) had breast‐fed their infants at birth. This rate dropped to 96.5% during the first week of life. There were 635 (64.1%) mothers who started to breast‐feed their babies within six hours of delivery. Over two thirds (68.9%) of mothers gave supplemental liquids to infants during the first 3 days of their life. More than half fed their infants on demand rather than on schedule. A high proportion (94.4%) breast‐fed at night, with 88.1% feeding their infants more than once. There was no significant relationship between the duration of suckling and the mother's age or work status (p > 0.05). However, a significant relationship (p < 0.001) was found between the duration of suckling and the mother's literacy. More than three quarters of mothers slept in the same bed with their infants or in the same room. A large percentage of women initiated breast‐feeding; however, many introduced a supplement too early, a practice that should be discouraged.     

The Educational Consequences of Adolescent Childbearing and Union Formation in Brazil

While Brazil has high rates of adolescent fertility for its below‐replacement total fertility rate, we know little about the causal effects of adolescent childbearing and adolescent union formation for women's education. In this paper, we examine unique data from the 2013 School‐to‐Work Transitions Survey to address the consequences of adolescent childbearing and adolescent union formation on educational outcomes of Brazilian young women. We apply several analytical strategies to address the endogeneity between adolescent childbearing and educational outcomes. Our findings suggest that childbearing during the teenage years is detrimental to the educational attainment of Brazilian women, and that educational disadvantages persist once we take into account mother's selection into adolescent childbearing. The penalty for adolescent mothers ranges from −1.66 to −1.80 fewer years of schooling and from 41 to 35 percent difference in the probabilities of graduating from high school. Additional findings show that marital unions among adolescent mothers have a compounding role at further hindering women's educational progress. Combined, our findings suggest that young mothers, particularly those in a marital union, face additional layers of disadvantages, demonstrating that early family formation is a meaningful stratifier for women in an already highly‐stratified society.     

Health insurance coverage among women in Indonesia's major cities: A multilevel analysis

We examined women's access to health insurance in Indonesia. We analyzed IFLS-4 data of 1,400 adult women residing in four major cities. Among this population, the health insurance coverage was 24%. Women who were older, involved in paid work, and with higher education had greater access to health insurance (p < .05). We also found there were disparities in the probability of having health insurance across community levels (Median Odds Ratios = 3.40). Given the importance of health insurance for women's health, strategies should be developed to expand health insurance coverage among women in Indonesia, including the disparities across community levels. Such problems might also be encountered in other developing countries with low health insurance coverage.     

BIRTH WEIGHT AND FAMILY STATUS REVISITED: EVIDENCE FROM AUSTRIAN REGISTER DATA

In this paper, we study the socio‐economic determinants of birth weight, with a focus on the mother's family status. We use Austrian birth register data covering all births between 1984 and 2007 and find that a mother's marriage is associated with a higher birth weight of the newborn, in the range of 40 to 60 g. The significant impact is retained if we include mother fixed effects or use an instrumental variable approach to account for unobserved mother heterogeneity. However, the magnitude of the causal effect (37 g) clearly indicates the importance of selection into marriage. Divorce around pregnancy results in significantly lower birth weights than the birth weights of babies born to single mothers. Family status effects in the 2000s are stronger than they were in the 1980s, and quantile regressions suggest that family effects are more pronounced at the lower quantiles of the birth weight distribution and less pronounced at higher quantiles. We conclude that the life situation of expectant mothers has an important influence on the birth weight of newborns, especially at the lower tail of the birth weight distribution. Copyright © 2013 John Wiley & Sons, Ltd.     

The Affordable Care Act's insurance market regulations' effect on coverage

Much of the debate surrounding reform of the Patient Protection and Affordable Care Act (ACA) revolves around its insurance market regulation. This paper studies the impact on health insurance coverage of those provisions. Using data from the American Community Survey, years 2008–2015, I focus on individuals, ages 26 to 64, who are ineligible for the subsidies or Medicaid expansions included in the ACA to isolate the effect of its market regulation. To account for time trends, I utilize a differences‐in‐differences approach with a control group of residents of Massachusetts who were already subject to a similarly regulated health insurance market. I find that the ACA's regulations caused an increase of 0.95 percentage points in health insurance coverage for my sample in 2014. This increase was concentrated among younger individuals, suggesting that the law's regulations ameliorated adverse selection in the individual health insurance market.     

Experiences of social work intervention among mothers with perinatal mental health needs

Perinatal mental health difficulties are prevalent among women, and the vulnerability of young infants makes this a time when families experiencing multiple adversities may be particularly likely to attract state intervention. However, very little is known about how mothers experience social work intervention during the perinatal period. This study explored experiences of social work intervention among women with perinatal mental health difficulties. Qualitative semi‐structured interviews were carried out with 18 women with 6‐ to 9‐month‐old babies, who had been treated in England for a perinatal mental health difficulty and also had social services intervention. Interviews were analysed using thematic analysis. Findings suggested that mothers had a predominantly negative view of children's social services, especially when social workers had significant child protection concerns. The fear of being judged an unfit mother and having their babies taken away overshadowed their encounters. Mothers felt that social workers would not accept they could be good mothers in spite of their difficulties and set them up to fail. Some felt that social workers focused exclusively on the risks to the baby and did not acknowledge the mother's own needs or understand perinatal mental health. In some cases, social work intervention was described as intensifying pressure on mothers’ mental health, leading to escalating difficulties and increased likelihood of care proceedings. At the same time, our study also included examples of mothers forming positive relationships with social workers, and of ‘turning points’ where initially negative interactions stabilised and child protection concerns lessened. Women's accounts highlighted the importance of feeling ‘known’ by social workers who understood and respected them. The findings also suggested there may be value in improving collaboration between social workers and mental health professionals to create more space for representation of women's needs as well as those of their babies.     

Mothering While Imprisoned: The Effects of Family and Child Dynamics on Mothering Attitudes

Since the early 1990s, the number of children with imprisoned mothers has increased 131%. A mother's imprisonment potentially exposes children to a concentrated disadvantage that undermines their cognitive, emotional, and intellectual abilities. Additionally, such experiences can have deleterious effects on mother‐child relationships, stand‐in caregivers, foster care caseloads, the penal system, and society. Less may be understood, however, about how imprisonment affects the ways in which women view themselves as mothers. This study examines mothering attitudes for a sample of 210 Black, White, and Hispanic imprisoned mothers. Nested modeling results suggest a positive relationship between favorable views about mothering and children's profiles and mothers' expectations about future custody. Regular contact with their children through letter writing and telephone calls foster the most favorable views.     

Transitions from private to public health coverage among children: estimating effects on out-of-pocket medical costs and health insurance premium costs

Objective. To assess the effects of transitions from private to public health insurance by children on out‐of‐pocket medical expenditures and health insurance premium costs. Data Sources. Data are drawn from the 1996 and 2001 panels of the Survey of Income and Program Participation. We construct a nationally representative, longitudinal sample of children, ages 0–18, and their families for the period 1998–2003, a period in which states raised public health insurance eligibility rates for children. Study Design. We exploit the Survey of Income and Program Participation's longitudinal design to identify children in our sample who transition from private to public health insurance. We then use a bootstrapped instrumental variable approach to estimate the effects of these transitions on out‐of‐pocket expenditures and health insurance premium costs. Principal Findings. Children who transition from private to public coverage are relatively low‐income, are disproportionately likely to live in single‐mother households, and are more likely to be Black or of Hispanic origin. Child health status is highly predictive of transitions. We estimate that these transitions provide a cash‐equivalent transfer of nearly U.S.$1,500 annually for families in the form of reduced out‐of‐pocket and health insurance premium costs. Conclusions. Transitions from private to public health coverage by children can bring important social benefits to vulnerable families. This suggests that instead of being a net societal cost, such transitions may provide an important social benefit.     

Determinants of Infant-Feeding Choice Among Young Women in Hilo,Hawaii

Our multicultural island community is unique in that many young mothers live in multigenerational households. In this qualitative study, we examined the factors that influenced young mothers’ infant-feeding practices in Hilo, a small rural town in the Hawaiian Islands. The study participants consisted of young mothers, health care professionals, and educators. Our findings suggest that both the young mother's mother and her partner are very influential in the infant-feeding decision. Many young women in our study bottle fed to obtain assistance in caretaking, and to facilitate public breastfeeding. Additionally, we explored young mother's views of sexuality and breastfeeding, and their health promotion implications.     

Zoe's Story: Exploring the Complexity of “Help-providing” and “Help-receiving” Relationships on the “Front-line” of Family Support

The subject of engaging mothers in appropriate family support continues to be debated and this paper explores the complex factors that influenced one mother's willingness to accept support. In addition, it captures how her family support worker built and sustained a “help-providing” and “help-receiving” relationship despite the mother's resistance. This paper reports on data that were gathered as part of a larger research study based in two Sure Start Children's Centres and draws on one case study as an exemplar that illustrates the nature of family support. By presenting Zoe's story, this paper draws on personal construct theory to examine the reasons why one mother refused to engage in support services based on her negative self-construct. The findings identify that the building and sustaining of relationships with vulnerable and excluded mothers is complex and requires workers to manage and negotiate their everyday interactions and adapt the support offered. In addition, they identify how these “help-providing” and “help-receiving” relationships enable mothers to access the support that they need and refine their negative self-constructs and predict more positive outcomes for their family.     

Did the Affordable Care Act's dependent coverage mandate increase premiums?

We investigate the impact of the Affordable Care Act's dependent coverage mandate on insurance premiums. The expansion of dependent coverage under the ACA allows young adults to remain on their parent's private health insurance plans until the age of 26. We find that the mandate has led to a 2.5–2.8 percent increase in premiums for health insurance plans that cover children, relative to single-coverage plans. We are able to conclude that employers did not pass on the entire premium increase to employees through higher required plan contributions.     

Health insurance enrolment in the Upper West Region of Ghana: Does food security matter?

Toward achieving universal health coverage, Ghana's national health insurance has been acclaimed as a pro‐poor scheme, yet been criticized for leaving the poor behind. Arising from this is how poverty has been operationalized and how poor people are targeted for enrolment into the scheme. We examine the role of food insecurity (not currently considered) as a multidimensional vulnerability concept on enrolment into Ghana's health insurance using binary logistics regression on cross‐sectional survey of household heads (n = 1438) in the Upper West Region of Ghana. Our analyses show that heads of severely food‐insecure households were significantly less likely to enroll in national health insurance scheme (NHIS) relative to households who reported being food‐secure (OR = 0.36, P < .05). We also found education, occupation, and religion as significant predictors of health insurance enrolment. Based on our findings, it is crucial to incorporate food security status in the identification of vulnerable people for free enrolment in Ghana's health insurance.