The effect of Medicaid eligibility expansions on fertility

In the United States, pregnant women and children’s eligibility for Medicaid was expanded dramatically during the 1980s and early 1990s. By lowering pregnancy and child health care costs, the Medicaid expansions may have increased the incentives for women to have children. To investigate this possibility, we examine whether state-level birth and abortion rates are related to the extent of states’ Medicaid eligibility expansions and the fraction of women eligible for Medicaid, controlling for economic and demographic factors, during the period 1982 to 1996. We examine birth rates by race, marital status and education as well as overall abortion rates. We find little evidence that the Medicaid expansions led to changes in birth rates or abortion rates. However, some results do suggest that the Medicaid expansions boosted the birth rate among white women who have not completed high school. We find that restrictions on Medicaid funding of abortions decrease abortion rates and increase birth rates. The results thus do not provide definitive evidence that expansions in public health insurance eligibility have sizable effects on women’s fertility.     

Medicaid reimbursement,prenatal care and infant health

This paper evaluates the impact of state-level Medicaid reimbursement rates for obstetric care on prenatal care utilization across demographic groups. It also uses these rates as an instrumental variable to assess the importance of prenatal care on birth weight. The analysis is conducted using a unique dataset of Medicaid reimbursement rates and 2001–2010 Vital Statistics Natality data. Conditional on county fixed effects, the study finds a modest, but statistically significant positive relationship between Medicaid reimbursement rates and the number of prenatal visits obtained by pregnant women. Additionally, higher rates are associated with an increase in the probability of obtaining adequate care, as well as a reduction in the incidence of going without any prenatal care. However, the effect of an additional prenatal visit on birth weight is virtually zero for black disadvantaged mothers, while an additional visit yields a substantial increase in birth weight of over 20 g for white disadvantaged mothers.     

Effects of psychosocial risk factors and prenatal interventions on birth weight: evidence from New Jersey's HealthStart program

CONTEXT: Many states developed and implemented multifaceted Medicaid prenatal care programs in the late 1980s in response to expansions in Medicaid eligibility. Although these new programs were based on the presumed relationships between psychosocial risk factors, early prenatal care, prenatal interventions and birth outcomes, research has not verified all of these linkages.
METHODS: Data were collected on 90,117 women who took part in New Jersey's comprehensive prenatal care program, Health Start, between 1988 and 1996. The impact of psychosocial risk factors and prenatal interventions on mean birth weight and the odds of low birth weight (less than 2,500 g) was assessed using ordinary least-squares regression and logistic regression, respectively.
RESULTS: After controls were introduced for social and demographic, psychosocial and behavioral factors, as well as the woman's county of residence and the year of her baby's birth, smoking, drinking and using hard drugs (but not marijuana) during pregnancy were independently associated with reductions in mean birth weight (of 123 g, 29 g and 137 g, respectively) and with increases in the odds of low birth weight (odds ratios, 1.4, 1.2 and 1.7, respectively). However, according to the fully adjusted model, which also controlled for medical risk factors and prenatal services, the interventions designed to reduce those behaviors had no favorable effects on birth weight. In contrast, the receipt of services in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) was associated with an increase in mean birth weight of 22 g (and of 48 g among inadequately nourished women only), and with a reduction in the risk of low birth weight (odds ratio, 0.87).
CONCLUSION: Referrals to WIC services should be a key feature of prenatal care programs for poor women.     

An evaluation of the impact of maternity care coordination on Medicaid birth outcomes in North Carolina.

BACKGROUND. Care coordination is an important component of the enhanced prenatal care services provided under the recent expansions of the Medicaid program. The effect of maternity care coordination services on birth outcomes in North Carolina was assessed by comparing women on Medicaid who did and did not receive these services. METHODS. Health program data files, including Medicaid claims paid for maternity care coordination, were linked to 1988 and 1989 live birth certificates. Simple comparisons of percentages and rates were supplemented by a logistic regression analysis. RESULTS. Among women on Medicaid who did not receive maternity care coordination services, the low birth weight rate was 21% higher, the very low birth weight rate was 62% higher, and the infant mortality rate was 23% higher than among women on Medicaid who did receive such services. It was estimated that, for each $1.00 spent on maternity care coordination, Medicaid saved $2.02 in medical costs for newborns up to 60 days of age. Among the women who did receive maternity care coordination, those receiving it for 3 or more months had better outcomes than those receiving it for less than 3 months. CONCLUSIONS: These results suggest that maternity care coordination can be effective in reducing low birth weight, infant mortality, and newborn medical care costs among babies born to women in poverty.     

Infant health consequences of childbearing by teenagers and older mothers

The association of childbearing at early and late ages with various adverse outcomes of pregnancy was explored in data collected in the 1980 National Natality and Fetal Mortality Surveys. The characteristics of interest for teenage mothers were marital status at conception and the trimester of pregnancy in which prenatal care was begun. For married mothers aged 30 years and older, the variables considered were employment status and occupation during the year preceding childbirth and smoking status before and during pregnancy. The pregnancy outcome variables analyzed were the same for both groups of mothers: fetal loss, low birth weight, and low 1-minute Apgar scores. Although more than half of all births to teenage mothers were to unmarried women, an additional one-quarter of these births were to women who married between the time of conception and the birth of the child. Generally there was little difference in outcomes for teenage mothers who were married at the time of delivery, regardless of their marital status at the time of conception. Pregnancy outcomes for teenagers who did not marry prior to delivery were considerably less favorable. Nearly 90 percent of women aged 30-34 years who had a first birth in 1980 were employed during the year before delivery, an extraordinarily high labor force participation rate. More than half of these employed mothers were in professional occupations, consistent with their very high levels of educational attainment. Although the analysis is limited by the small numbers of births involved, it appears that professionally employed women generally have the best pregnancy outcomes. When mother's smoking status is taken into account,nonsmokers had more favorable outcomes, with births to professionally employed mothers generally most favored.     

Using 1990 national MCH objectives to assess health status and risk in an American Indian community

The authors used data from birth records to assess changes in health risks and health status of American Indians (AI) living in Umatilla County, OR, from 1973 to 1986. They compared the AI health risks and health status with those of other persons (non-AI) living in Umatilla County, and assessed the progress of both AI and non-AI populations toward selected 1990 national health objectives. This AI population is likely to achieve the 1990 national health objective calling for less than 5 percent of births to be low birth weight (LBW); the LBW rate decreased from 5.0 percent in 1977-80 to 4.1 percent in 1984-86. However, the population is not likely to achieve the 1990 objective calling for at least 90 percent of women to begin prenatal care during the first trimester, even though the proportion of AI women who began prenatal care in the first trimester increased from 42.3 percent in 1973-76 to 62.6 percent in 1984-86. The Yellowhawk Indian Health Center began offering clinical services to AI in Umatilla County in 1976. Compared with non-AI women, AI women closed large gaps in key health risk and health status indicators during the period from 1973 to 1986. For example, from 1973 to 1976, 14.6 percent of AI mothers compared with 6.3 percent of non-AI mothers began prenatal care in the last trimester. By 1984 to 1986, only 9.0 percent of AI and 7.9 percent of non-AI mothers began prenatal care in the last trimester. Several other desirable health indicators improved more for AI than for non-AI from 1973 to 1986.(ABSTRACT TRUNCATED AT 250 WORDS)     

Pregnant women eligible under Medicaid expansion of maternity services. Implications for outreach.

Recent reforms in federal legislation have made Medicaid-financed prenatal care available to pregnant women from households at nearly twice the poverty level. Census and birth certificate data provide little information about the newly eligible group beyond estimates of their size. This article reports on efforts to compare the Medicaid expansion group to traditional Medicaid prenatal care patients in terms of demographics, access problems, and prenatal care adequacy by employing a short-term, hospital-based survey of postpartum women in Michigan. Differences between pregnant women eligible under the expansions and traditionally eligible pregnant women suggested that major changes in outreach and enrollment activities of state Medicaid agencies may be necessary to fulfill the opportunity represented by the Medicaid expansions.     

A comparison of low birth weight among Medicaid patients of public health departments and other providers of prenatal care in North Carolina and Kentucky.

Matching of Medicaid and health department patients' files to birth certificates was used as a means of evaluating the effect of prenatal care given by public health departments on the birth weights of babies of women in Medicaid. Three years of live birth data from North Carolina and 2 years of birth data from Kentucky were used in the analysis. After controlling for other low birth weight risk factors (including the quantity of prenatal care) with logistic regression, women in Medicaid who received prenatal care outside public health departments were found to be substantially more likely than those who received care at health departments to have low weight infants. This association was especially strong for births under 1,500 grams. The authors suggest that the comprehensive prenatal care that is provided by the public health departments, which includes various nonmedical support services, may be responsible for this difference. These findings have important implications for proposed expansions of the Medicaid Program to cover more pregnant women in poverty.     

Managed care and infant health: an evaluation of Medicaid in the US

In this study, we examine the effects of Medicaid managed care (MMC) on prenatal care utilization, infant birth weight, pre-term birth, and use of cesarean section in the United States. We obtain separate estimates of the effect of primary care case management managed care programs and health maintenance organization managed care plans on these outcomes. The results suggest the following: among white, non-Hispanic women, MMC was associated with a 2 percent decrease in the number of prenatal care visits and a 3-5 percent increase the incidence of inadequate prenatal care; MMC was associated with a significant increase in the incidence pre-term birth for non-Hispanic white women, but that this association does not appear to be causal; and MMC had no association with the incidence of cesarean section.     

Prenatal care and infant birth outcomes among Medicaid recipients

Infant morbidity due to low birth weight and preterm births results in emotional suffering and significant direct and indirect costs. African American infants continue to have worse birth outcomes than white infants. This study examines relationships between newborn hospital costs, maternal risk factors, and prenatal care in Medicaid recipients in an impoverished rural county in South Carolina. Medicaid African American mothers gave birth to fewer preterm infants than did non-Medicaid African American mothers. No differences in the rates of preterm infants were noted between white and African American mothers in the Medicaid group. Access to Medicaid services may have contributed to this reduction in disparities due to race. Early initiation of prenatal care compared with later initiation did not improve birth outcomes. Infants born to mothers who initiated prenatal care early had increased morbidity with increased utilization of hospital services, suggesting that high-risk mothers are entering prenatal care earlier.     

Health service use and outcomes among disabled Medicaid pregnant women

PURPOSE: We investigated differences in health service use and pregnancy outcomes among women enrolled in Medicaid under eligibility categories for the blind and disabled and those enrolled under other eligibility categories. METHODS: We used Medicaid enrollment and claims data to create episodes of pregnancy- and delivery-related care for women with and without disabilities who had Medicaid-covered deliveries in Florida, Georgia, and New Jersey during 1995 and Texas during 1997. We linked birth certificate information on prenatal care and birth outcomes to the files for Georgia and Texas. We then computed the unadjusted and adjusted odds ratios for the receipt of selected routine prenatal and illness-related services and the occurrence of selected pregnancy outcomes among women with disabilities relative to women without disabilities. FINDINGS: In all states, women with disabilities were more likely than women without disabilities to have had continuous Medicaid coverage from preconception through the postnatal period. Women with disabilities were equally or less likely to have received adequate prenatal care compared to women without disabilities in the two study states with these data. They were also more likely to have had emergency room visits, hospital admissions during pregnancy, cesarean deliveries, and readmissions within 3 months of delivery in all study states. We also found women with disabilities to have been more likely to deliver preterm and low birthweight infants. CONCLUSION: Our results suggest that opportunities exist to improve access to prenatal care among women with disabilities enrolled in Medicaid under blind and disabled eligibility categories who become pregnant.     

Access for pregnant women on Medicaid: variation by race and ethnicity

Disparities in early and adequate prenatal care and infant/maternal outcomes still exist between white and nonwhite populations. Although Medicaid expansions were intended to improve outcomes, eligible women often delay enrollment and access barriers remain. This study examines racial disparities among pregnant women in Florida, Georgia, New Jersey, and Texas. The disproportionate location of minorities enrolled in Medicaid in urban areas with greater physician supply was not found to increase office-based prenatal care among blacks. More local physicians, especially foreign medical graduates, sometimes increased access, largely for Hispanics. The presence and use of safety net providers did increase prenatal care use among minorities. This evidence lends support to policies to maintain safety net providers, which are perhaps better equipped than others to serve low-income populations. However, policies should encourage participation extending to all racial/ethnic groups by office-based physicians. The role of foreign medical graduates, who are more likely to participate in Medicaid, should be considered.     

Teenage pregnancy and adverse birth outcomes: a large population based retrospective cohort study

BACKGROUND: Whether the association between teenage pregnancy and adverse birth outcomes could be explained by deleterious social environment, inadequate prenatal care, or biological immaturity remains controversial. The objective of this study was to determine whether teenage pregnancy is associated with increased adverse birth outcomes independent of known confounding factors. METHODS: We carried out a retrospective cohort study of 3,886,364 nulliparous pregnant women <25 years of age with a live singleton birth during 1995 and 2000 in the United States. RESULTS: All teenage groups were associated with increased risks for pre-term delivery, low birth weight and neonatal mortality. Infants born to teenage mothers aged 17 or younger had a higher risk for low Apgar score at 5 min. Further adjustment for weight gain during pregnancy did not change the observed association. Restricting the analysis to white married mothers with age-appropriate education level, adequate prenatal care, without smoking and alcohol use during pregnancy yielded similar results. CONCLUSIONS: Teenage pregnancy increases the risk of adverse birth outcomes that is independent of important known confounders. This finding challenges the accepted opinion that adverse birth outcome associated with teenage pregnancy is attributable to low socioeconomic status, inadequate prenatal care and inadequate weight gain during pregnancy.     

A comparison of capitated and fee-for-service Medicaid reimbursement methods on pregnancy outcomes.

OBJECTIVE: To determine if the payment method influenced the likelihood of selected obstetrical process measures and pregnancy outcome indicators among Medicaid women. DATA SOURCE/STUDY SETTING: Data from the live birth certificates computer file for 1993 from the State of California. The computer files contain information about the demographic characteristics of the mother, her medical conditions prior to delivery, medical problems during labor and delivery, delivery method, newborn and maternal outcomes, and expected principal source of payment for prenatal care and for hospital delivery. STUDY DESIGN: The study sample consisted of singleton live births to women in the California Medi-Cal program residing in one of two counties in which a mixed-model managed care plan was the method of reimbursement or in one of three counties in which fee-for-service was the payment method. The study and control counties were matched in terms of geographic proximity and sociodemographics. PRINCIPAL FINDINGS: Among Medi-Cal women, the likelihood of low birth weight (LBW) was lower in the capitated payment group than in the fee-for-service payment group even when controlling for maternal and newborn characteristics and adequacy of prenatal care. There was no difference in either the adequacy of prenatal care, the cesarean birth rate, or the likelihood of adverse pregnancy outcomes other than LBW between the two payer groups. CONCLUSIONS: Results of this "natural experiment" suggest that enrollment of pregnant Medi-Cal beneficiaries in capitated healthcare services through a primary care case management system in a county-organized health system/health insuring organization can have a beneficial effect on low birth weight and provide care comparable to a fee-for-service system.     

Socioeconomic and work related determinants of pregnancy outcome in southern Thailand

STUDY OBJECTIVE: To examine the effect of socioeconomic status on pregnancy outcome in an urbanised area in a rapidly developing country. METHODS: A cohort of 1797 pregnant women who attended antenatal care clinics at the two 700 bed hospitals in Hatyai city was recruited from September 1994 to November 1995. The pregnant women were followed up from the 17th week of gestation until delivery. The socioeconomic indicators selected were family socioeconomic status, maternal education, maternal occupation, family income and work exposure characteristics based upon Karasek's job content questionnaires. Pregnancy outcomes were birth weight, low birth weight, small for gestational age and preterm delivery. MAIN RESULTS: Mean birth weight correlated with socioeconomic status and income but after adjustment for parity, maternal age and height, weight at delivery day, baby sex, obstetrical complications and antenatal care utilisation, only family income remained correlated with birth weight. No association with any socioeconomic status indicators was found when using dichotomous outcome (low birth weight, small for gestational age or preterm delivery). Only high psychological job demand was associated with small for gestational age. Confounder adjustment indicated that the observed social status differences in pregnancy outcomes were mainly attributable to mother's characteristics and antenatal service use. CONCLUSIONS: Socioeconomic indicators alone were not associated with reduced fetal growth or preterm delivery in this study, which recruited mainly lower or middle class women. Karasek's psychological job demand was only weakly correlated with small for gestational age infant.     

Medicaid and pregnant women: who is being enrolled and when

Medicaid eligibility expansions and improved enrollment procedures for pregnant women during the late 1980s are examined in this article. Results show that the number of births financed by Medicaid has increased dramatically, and that women are enrolling earlier in the course of pregnancy. Nevertheless, problems continue to exist. If substantial numbers of women continue to enroll late in pregnancy, the expansions may not promote significantly earlier use of prenatal care.     

The effects of Florida's Medicaid eligibility expansion for pregnant women.

OBJECTIVES: This is a study of the effects on prenatal care and birth outcomes of Florida's July 1989 expansion in the Medicaid income eligibility threshold for pregnant women. METHODS: Concurrent and longitudinal comparisons were performed with matched birth and death certificates, hospital discharge data, Medicaid eligibility records, and records from county health departments for women giving birth from July 1988 to June 1989 (n = 56,101) or in calendar year 1991 (n = 78,421). Measures included amount and timing of prenatal care and rates of low birthweight and infant deaths. RESULTS: The Medicaid expansion led to greater access and improved birth outcomes. For example, the rate of low-birthweight infants among low-income women without private insurance fell from 67.9 to 61.8 per 1000, while it remained unchanged for low-income women with private insurance. Women in the expansion group who used county health departments had fewer low-birthweight infants than those using other delivery systems. CONCLUSIONS: The benefits from the Florida expansion appear to be greater than those reported for other states. The role of the public health delivery system may account for some of Florida's success.     

Obstetric care and payment source: do low-risk Medicaid women get less care?

OBJECTIVES: This study examined whether Medicaid-insured women at low risk receive less adequate obstetrical care than privately insured women. METHODS: Low-risk women who were cared for by a random sample of obstetrical providers in Washington State were randomly selected. Information on all prenatal and intrapartum services was abstracted from medical records. Service information was aggregated into standardized resource-use units. Results compared Medicaid-insured women with those who were privately insured. RESULTS: Medicaid-insured women were significantly younger (22.5 years vs 26.9 years) and averaged 6% fewer visits than privately insured women. Nonetheless, Medicaid status had no meaningful association with prenatal, intrapartum, or overall resource use. Some variation occurred in individual resources received. Medicaid-insured women had 38.8% more resources expended on testing for sexually transmitted diseases. Privately insured women had more resources expended on alpha-fetoprotein testing and on amniocentesis. There were no meaningful differences in birthweight or gestational age at delivery. CONCLUSIONS: In this study of women who entered obstetrical care at low risk, similar care and resources were expended on Medicaid-insured and on privately insured women.     

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.     

Sociodemographic factors and the quality of prenatal care.

BACKGROUND: In this study, maternal sociodemographic factors are examined in relationship to the quality of prenatal health services US women receive. METHODS: Data from the 1980 National Natality Survey and 1980 Fetal Mortality Survey were used for the analysis. Indicator variables for prenatal care quality are the percentages of prenatal visits at which blood pressure and urine were tested, the performance of hemoglobin or hematocrit tests, and the presence or absence of advice regarding salt restriction and diuretics usage during pregnancy. RESULTS: Distribution of the basic examinations in prenatal care vary according to marital status, parity, education, and residence in a metropolitan or nonmetropolitan county. The advice received concerning salt and diuretics usage was also influenced by sociodemographic variables. CONCLUSIONS: The analyses reveal that prenatal care is not of even minimally acceptable quality for many women.