Background
Changes to the Medicaid program in early 1990’s:
The Forgotten Beneficiary of
the Medicaid Expansions
¾
¾
eligibility thresholds increased
two-parent families started to qualify
Potential beneficiaries – low income individuals:
Andrea Kutinova and Karen Smith Conway
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¾
¾
Department of Economics
University of New Hampshire
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.”
Measuring Maternal Health
Why Study Maternal Health?
• no generally recognized measure (no “analog to BWT”)
• 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
• use pregnancy & delivery complications which:
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¾
• 4 measures of maternal health – incidences of:
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¾
• Medicaid: help disadvantaged pregnant women and their
infants and children
are known to be preventable by PNC
are recorded in birth certificates
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¾
anemia
pregnancy-related hypertension
placental abruption
“any complication” (a summary variable)
Data
Empirical Strategy
• variations in Medicaid eligibility across states & over time
•
difference-in-differences type of approach:
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• Natality Detail Files, 1989-1996
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treatment groups: low SES women (edu < 12, 12, 13-15)
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ƒ
married: gained eligibility
single: might have been eligible before expansions X some
benefited from increased eligibility thresholds + affected by
welfare declines (AFDC)
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• sample restrictions:
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non-Hispanic blacks and whites
19 ≤ age ≤ 50
singleton births
Æ
10,855,048 observations
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use a 1/3 random sub-sample of the white control population
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¾
¾
control group: high SES married women (edu ≥ 16)
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most unlikely to be affected
• “straw man” complication: diabetes
strengths: 100% of U.S. births
info on maternal & infant morbidity, individual
characteristics, characteristics of the pregnancy
weakness: no info on income Æ proxy with education
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Models
Descriptive Statistics – PNC Utilization
PNC utilization/maternal health = f(Medicaid eligibility,
welfare caseload, unemployment, individual
characteristics, state&year dummies)
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.
• PNC utilization:
¾
¾
PNC in the first trimester
“adequate” or “intermediate” PNC
• maternal health:
¾
anemia, hypertension, placental abruption, “any complication”,
diabetes (“straw man”)
• Medicaid eligibility:
¾
¾
state & time specific income cutoff (% of federal poverty line)
lagged by 6 months
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)
¾ married women receive earlier & more adequate care
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¾
• estimate separately for treatment and control groups
• stratify by race
• estimate with logit and LPM (SEs adjusted for clustering by state/year)
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trends: PNC use increased substantially in the 1990’s
(strongest for very-low SES cohorts)
Anemia (1990-1999)
Descriptive Statistics – Maternal Health
Trends in
Maternal Health
in the 1990’s
4,5
4
Anemia (%)
Hypertension
(%)
Placental
abruption (%)
Diabetes (%)
3.49
1.93
Treatment group#2
(edu < 12, single)
1,343,645 obs.
Black
White
46.14%
53.86%
3.86
2.23
Control group
(edu ≥ 16, married)
4,690,938 obs.
Black
White
5.94%
94.06%
2.48
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 W hite
High Income W hite
Hypertension (1990-1999)
1.14
2.45
2.47
2.04
2.29
3.62
2.95
increased incidences of
anemia and hypertension
0.81
0.79
0.86
0.89
0.55
0.48
¾
3.21
2.57
1.54
1.92
3.51
2.34
4,5
¾
4
Incidence (%)
Treatment group#1
(edu < 12, married)
1,244,580 obs.
Black
White
10.78%
89.22%
Incidence (%)
3,5
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
black women more anemia (for both SES levels)
incidences of hypertension and placental abruption similar across races
¾ hypertension more frequent among high SES mothers (age?)
¾ anemia and placental abruption more prevalent in low SES groups
¾ incidence of diabetes higher among married women
0,9
Incidence (%)
0,8
reporting? Æ use diabetes
as a “straw man”
0,75
¾
0,7
0,65
0,6
0,55
0,5
0,45
0,4
1990
1991
•
•
•
•
0.89
1.18***
0.95
0.89
1.16***
0.99
0.93
1.15***
0.91
0.97
1.06
0.85
1.07
0.84
1.06
0.92
0.90
0.90
0.90*
0.93
0.96
0.90
0.94
0.93
0.94
0.98
0.98
1994
1995
1996
Low Income W hite
1997
1998
1999
High Income W hite
PNC in Placental Anemia Hypertension
Any
first
abruption
complication
trimester
Diabetes
0.87*
PNC utilization increases
odds of hypertension (and possibly anemia) fall
odds of “any complication” reduced
effects marginally significant Æ suggestive results
1993
High Income Black
Effects of Medicaid on PNC Use and Maternal
Health: Whites; Odds Ratios
Effects of Medicaid on PNC Use and Maternal
Health: Blacks; Odds Ratios
1.09
1992
Year
Low Income Black
1.00
High Income W hite
0,85
¾
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)
Low Income W hite
Placental Abrupt. (1990-1999)
¾
PNC in Placental Anemia Hypertension
Any
first
abruption
complication
trimester
High Income Black
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
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Conclusion
• strongly suggestive evidence that pregnant women were an
additional beneficiary of the Medicaid eligibility
expansions
• in particular, our results indicate that:
¾ utilization of PNC increased
¾ incidence of hypertension significantly decreased
¾ incidence of anemia decreased (significant when
compared to diabetes)
¾ racial difference: benefits to white women stronger
Questions and Comments Appreciated
kutinova@cisunix.unh.edu
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