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 (edu < 12, married)

1,244,580 obs.

Treatment group#2 (edu < 12, single)

1,343,645 obs.

Control group (edu ≥ 16, married)

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.

Treatment group#2 (edu < 12, single)

1,343,645 obs.

Control group (edu ≥ 16, married)

4,690,938 obs.

Black 10.78%

White 89.22%

Black 46.14%

White 53.86%

Black 5.94%

White 94.06%

Anemia (%) 3.49 1.93 3.86 2.23 2.48 1.14 Hypertension (%)

2.45 2.47 2.04 2.29 3.62 2.95

Placental abruption (%)

0.81 0.79 0.86 0.89 0.55 0.48

Diabetes (%) 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

Hypertension (1990-1999)

1,5

2

2,5

3

3,5

4

4,5

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

Year

Inc

ide

nc

e (

%)

Low Income Black High Income Black Low Income White High Income White

Placental Abrupt. (1990-1999)

0,4

0,45

0,5

0,55

0,6

0,65

0,7

0,75

0,8

0,85

0,9

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

Year

Inc

ide

nc

e (

%)

Low Income Black High Income Black Low Income White High Income White

Trends in

Maternal Health in the 1990’s

increased incidences of anemia and hypertension

placental abruption: no change or slight decline

reporting? use diabetes as a “straw man”

Anemia (1990-1999)

0,5

1

1,5

2

2,5

3

3,5

4

4,5

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

Year

Inc

ide

nc

e (

%)

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 utilization increases• odds of hypertension (and possibly anemia) fall• odds of “any complication” reduced• effects marginally significant suggestive results

PNC in first

trimester

Placental abruption

Anemia Hypertension Any complication

Diabetes

Treatment group #1 (edu < 12, married)

1.00 1.09 0.89 0.84 0.87* 1.06

Treatment group #2 (edu < 12, single)

1.18*** 0.95 0.89 0.92 0.90 0.90

Treatment group #3 (edu = 12, single)

1.16*** 0.99 0.93 0.90* 0.93 0.96

Treatment group #4 (edu = 13-15, single)

1.15*** 0.91 0.97 0.90 0.94 0.93

Control group (edu ≥ 16, married)

1.06 0.85 1.07 0.94 0.98 0.98

Effects of Medicaid on PNC Use and Maternal

Health: Whites; Odds Ratios

• 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

PNC in first

trimester

Placental abruption

Anemia Hypertension Any complication

Diabetes

Treatment group #1 (edu < 12, married)

1.00 1.02 0.90 0.83*** 0.88*** 0.97

Treatment group #2 (edu < 12, single)

1.14*** 0.92 0.91 0.86** 0.89** 1.07

Treatment group #3 (edu = 12, single)

1.11*** 1.02 0.93 0.93* 0.95 1.20***

Treatment group #4 (edu = 13-15, single)

1.12*** 0.99 0.92 0.95 0.96 1.16**

Control group (edu ≥ 16, married)

0.97 0.98 1.08 0.99 1.01 1.11**

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