The Forgotten Beneficiary of
the Medicaid Expansions
Andrea Kutinova and Karen Smith Conway
Department of Economics
University of New Hampshire
Background
Changes to the Medicaid program in early 1990’s:


eligibility thresholds increased
two-parent families started to qualify
Potential beneficiaries – low income individuals:



infants (Currie&Gruber 1996, 1997; Currie&Grogger 2002)
children (Kaestner 2001)
mothers
“… without estimating the impacts of the expansions on maternal health
(in additions to infant and child health), any evaluation of the
effectiveness of the policy is incomplete.”
Why Study Maternal Health?
• Haas et al. (1993): “Although only 10 per 100,000 women
die from a complication of pregnancy or childbirth, 60% of
women receive medical care for some complication of
pregnancy, and 30% suffer from complications that result
in serious morbidity.”
• Healthy People 2010
• Medicaid: help disadvantaged pregnant women and their
infants and children
Measuring Maternal Health
• no generally recognized measure (no “analog to BWT”)
• use pregnancy & delivery complications which:


are known to be preventable by PNC
are recorded in birth certificates
• 4 measures of maternal health – incidences of:




anemia
pregnancy-related hypertension
placental abruption
“any complication” (a summary variable)
Empirical Strategy
• variations in Medicaid eligibility across states & over time
•
difference-in-differences type of approach:

treatment groups: low SES women (edu < 12, 12, 13-15)



married: gained eligibility
single: might have been eligible before expansions X some
benefited from increased eligibility thresholds + affected by
welfare declines (AFDC)
control group: high SES married women (edu ≥ 16)

most unlikely to be affected
• “straw man” complication: diabetes
Data
• Natality Detail Files, 1989-1996


strengths: 100% of U.S. births
info on maternal & infant morbidity, individual
characteristics, characteristics of the pregnancy
weakness: no info on income  proxy with education
• sample restrictions:

non-Hispanic blacks and whites
19 ≤ age ≤ 50
singleton births

10,855,048 observations

use a 1/3 random sub-sample of the white control population


Models
PNC utilization/maternal health = f(Medicaid eligibility,
welfare caseload, unemployment, individual
characteristics, state&year dummies)
• PNC utilization:


PNC in the first trimester
“adequate” or “intermediate” PNC
• maternal health:

anemia, hypertension, placental abruption, “any complication”,
diabetes (“straw man”)
• Medicaid eligibility:


state & time specific income cutoff (% of federal poverty line)
lagged by 6 months
• estimate separately for treatment and control groups
• stratify by race
• estimate with logit and LPM (SEs adjusted for clustering by state/year)
Descriptive Statistics – PNC Utilization
Treatment group#1 Treatment group#2
Control group
(edu < 12, married) (edu < 12, single) (edu ≥ 16, married)
1,244,580 obs.
1,343,645 obs.
4,690,938 obs.
Black
10.78%
White
89.22%
Black
46.14%
White
53.86%
Black
5.94%
White
94.06%
PNC in first
trimester (%)
62.51
70.86
53.11
63.46
90.18
95.15
Adequate or
intermediate
PNC (%)
84.21
90.22
75.47
86.94
97.59
99.04
black women start PNC later & are less likely to get adequate care
 PNC utilization increases with SES (education)
 married women receive earlier & more adequate care


trends: PNC use increased substantially in the 1990’s
(strongest for very-low SES cohorts)
Descriptive Statistics – Maternal Health
Treatment group#1
(edu < 12, married)
1,244,580 obs.
White
Black
89.22%
10.78%
Treatment group#2
(edu < 12, single)
1,343,645 obs.
White
Black
53.86%
46.14%
Control group
(edu ≥ 16, married)
4,690,938 obs.
White
Black
94.06%
5.94%
Anemia (%)
3.49
1.93
3.86
2.23
2.48
1.14
Hypertension
(%)
Placental
abruption (%)
Diabetes (%)
2.45
2.47
2.04
2.29
3.62
2.95
0.81
0.79
0.86
0.89
0.55
0.48
3.21
2.57
1.54
1.92
3.51
2.34
black women more anemia (for both SES levels)
 incidences of hypertension and placental abruption similar across races
 hypertension more frequent among high SES mothers (age?)
 anemia and placental abruption more prevalent in low SES groups
 incidence of diabetes higher among married women

Anemia (1990-1999)
Trends in
Maternal Health
in the 1990’s
4,5
4
Incidence (%)
3,5
3
2,5
2
1,5
1
0,5
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
Year
High Income Black
Low Income Black
Low Income White
High Income White
Hypertension (1990-1999)
4,5
increased incidences of
anemia and hypertension

Incidence (%)
4
placental abruption: no
change or slight decline

3,5
3
2,5
2
1,5
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
Year
Low Income Black
High Income Black
Low Income White
High Income White
Placental Abrupt. (1990-1999)
0,9
0,85
Incidence (%)
0,8
reporting?  use diabetes
as a “straw man”
0,75

0,7
0,65
0,6
0,55
0,5
0,45
0,4
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
Year
Low Income Black
High Income Black
Low Income White
High Income White
Effects of Medicaid on PNC Use and Maternal
Health: Blacks; Odds Ratios
PNC in Placental Anemia Hypertension
Any
first
abruption
complication
trimester
Treatment group #1
(edu < 12, married)
Treatment group #2
(edu < 12, single)
Treatment group #3
(edu = 12, single)
Treatment group #4
(edu = 13-15, single)
Control group
(edu ≥ 16, married)
•
•
•
•
Diabetes
1.00
1.09
0.89
0.84
0.87*
1.06
1.18***
0.95
0.89
0.92
0.90
0.90
1.16***
0.99
0.93
0.90*
0.93
0.96
1.15***
0.91
0.97
0.90
0.94
0.93
1.06
0.85
1.07
0.94
0.98
0.98
PNC utilization increases
odds of hypertension (and possibly anemia) fall
odds of “any complication” reduced
effects marginally significant  suggestive results
Effects of Medicaid on PNC Use and Maternal
Health: Whites; Odds Ratios
PNC in Placental Anemia Hypertension
Any
first
abruption
complication
trimester
Treatment group #1
(edu < 12, married)
Treatment group #2
(edu < 12, single)
Treatment group #3
(edu = 12, single)
Treatment group #4
(edu = 13-15, single)
Control group
(edu ≥ 16, married)
•
•
•
•
Diabetes
1.00
1.02
0.90
0.83***
0.88***
0.97
1.14***
0.92
0.91
0.86**
0.89**
1.07
1.11***
1.02
0.93
0.93*
0.95
1.20***
1.12***
0.99
0.92
0.95
0.96
1.16**
0.97
0.98
1.08
0.99
1.01
1.11**
PNC utilization increases
odds of hypertension (and possibly anemia) fall
odds of “any complication” reduced
effects highly significant and significantly different between treatment
and control groups
Conclusion
• strongly suggestive evidence that pregnant women were an
additional beneficiary of the Medicaid eligibility
expansions
• in particular, our results indicate that:
 utilization of PNC increased
 incidence of hypertension significantly decreased
 incidence of anemia decreased (significant when
compared to diabetes)
 racial difference: benefits to white women stronger
Questions and Comments Appreciated
kutinova@cisunix.unh.edu