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The Efficacy of Medicaid Family Planning Waivers On Young Women: Difference-in-Difference Evidence from National Microdata Amy M. Wolaver Bucknell University.

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Presentation on theme: "The Efficacy of Medicaid Family Planning Waivers On Young Women: Difference-in-Difference Evidence from National Microdata Amy M. Wolaver Bucknell University."— Presentation transcript:

1 The Efficacy of Medicaid Family Planning Waivers On Young Women: Difference-in-Difference Evidence from National Microdata Amy M. Wolaver Bucknell University Health Economics Interest Group Meeting, ARM June 7, 2008

2 Alternative Views on Contraception When the history of civilization is written, it will be a biological history and Margaret Sanger will be its heroine." When the history of civilization is written, it will be a biological history and Margaret Sanger will be its heroine." – H.G. Wells Chastity: The most unnatural of the sexual perversions. Chastity: The most unnatural of the sexual perversions. –Aldous Huxley For most women, including women who want to have children, contraception is not an option; it is a basic health care necessity. For most women, including women who want to have children, contraception is not an option; it is a basic health care necessity. –Louise Slaughter You must strive to multiply bread so that it suffices for the tables of mankind, and not rather favor an artificial control of birth, which would be irrational, in order to diminish the number of guests at the banquet of life. You must strive to multiply bread so that it suffices for the tables of mankind, and not rather favor an artificial control of birth, which would be irrational, in order to diminish the number of guests at the banquet of life. –POPE PAUL VI, speech, Oct. 4, 1965 The best contraceptive is the word no - repeated frequently. The best contraceptive is the word no - repeated frequently. –M argaret Smith The best contraceptive is a glass of cold water: not before or after, but instead. The best contraceptive is a glass of cold water: not before or after, but instead. –Author Unknown

3 Introduction Half of pregnancies in US are unintended (Guttmacher Institute) Half of pregnancies in US are unintended (Guttmacher Institute) Teen pregnancy has fallen in US but remains higher than other countries Teen pregnancy has fallen in US but remains higher than other countries Problems with teen childbearing Problems with teen childbearing –Public costs (Medicaid, welfare, education) –Health of mother & infant (low birthweight, premature birth etc…)

4 Family Planning Coverage for Poor Women Medicaid accounts for over ½ of Federal funds for contraceptive services Medicaid accounts for over ½ of Federal funds for contraceptive services –More than Title X funds –Copays are prohibited –Federal matching rate more generous than for other Medicaid services

5 Medicaid Section 1115 Family Planning Waivers Provides limited (contraceptive, STD testing, counseling) benefits to additional persons not on regular Medicaid Provides limited (contraceptive, STD testing, counseling) benefits to additional persons not on regular Medicaid Must be budget neutral (to Medicaid) over 5 year period Must be budget neutral (to Medicaid) over 5 year period –90% federal matching rate for BC –Higher than other services –Justification: reduces more costly, but lower-matched Medicaid births –Additional public savings from related avoided costs

6 Political Considerations Most estimates find FP waivers cost-neutral or saving from federal perspectives Most estimates find FP waivers cost-neutral or saving from federal perspectives Attractive to states because of generous match rate Attractive to states because of generous match rate Public funding of contraception remains controversial Public funding of contraception remains controversial –Encourages teen sex? –Unintended consequences? –Religious objections to any contraception

7 Waiver History Two strategies: Two strategies: –Extending FP services after regular (post-partum) Medicaid loss: 1994 Rhode Island & SC post-partum extension –Raise Income cut-off for FP services: California PACT 1997 As of 2/1/08 Twenty-seven states have implemented As of 2/1/08 Twenty-seven states have implemented Variation in timing, eligibility rules, coverage of teens/males Variation in timing, eligibility rules, coverage of teens/males

8 Previous Research on Public Contraceptive Coverage May increase provider availability (Frost et al. 2004) May increase provider availability (Frost et al. 2004) Increases use, more effective BC methods (Forrest & Samara 1996) Increases use, more effective BC methods (Forrest & Samara 1996) Inattention to endogeneity may lead to underestimates of policy efficacy (Mellor 1998) Inattention to endogeneity may lead to underestimates of policy efficacy (Mellor 1998) Income-related waivers reduce state birth rates (Lindrooth & McCullough 2007) Income-related waivers reduce state birth rates (Lindrooth & McCullough 2007)

9 Methods Difference-in-difference-in-difference Difference-in-difference-in-difference –Create treatment group (eligible/would be eligible) based on waiver rules in policy & matched states –Two control groups: Medicaid eligible, ineligible for both FP & regular Medicaid

10 Methods, continued Stage 1: Difference-in-difference (DD) Stage 1: Difference-in-difference (DD) –Compare pre- & post-waiver outcomes of treatment & control groups within waiver states (DD1) –Repeat with treatment & control in matched/comparison states (DD2) Stage 2: Difference-in-difference-in- difference (DDD) Stage 2: Difference-in-difference-in- difference (DDD) –Compare first stage results = DD1-DD2

11 Regression Framework Because data are panel Because data are panel –same women in pre- & post-, tx & control groups; –policy variation also occurring as cohort ages, experiences life cycle fertility changes

12 Regression Framework, contd OLS & Fixed effects OLS & Fixed effects –Also includes time & state dummies –Individual fixed effects –Includes controls for age, menses y/n, Medicaid eligible, urban Linear probability models Linear probability models –Fixed effects complex in nonlinear models, can introduce biases (Greene 2004) –Interaction effects even more complex in nonlinear models (Ai & Norton 2003) –But, heteroskedasticity, predictions outside 0/1 bounds –Use LPM, correct standard errors for heteroskedasticity, check against WLS estimates

13 Data 1997 National Longitudinal Survey of Youth 1997 National Longitudinal Survey of Youth –Women aged 12-18 in 1997 –Annual waves available from 1997-2005 –Only women 14 or older Policy information from Guttmacher Institute, cross checked with CMS Policy information from Guttmacher Institute, cross checked with CMS

14 Outcomes Childbearing Childbearing –Pregnant since last interview –Gave birth since last interview –Pregnant w/out live birth (abortion, miscarriages & still births combined) since last interview Contraceptive use Contraceptive use –At last intercourse –Typical pregnancy risk w/ usual BC method –Percent of time use BC Sexually active since last interview Sexually active since last interview

15 Policy Variation VariableFraction of Sample In a Waiver state (pre or post waiver)55.9 (49.7) In a state with income eligibility waiver (pre or post waiver)36.4 (48.1) In any Medicaid loss extension waiver state (pre or post waiver)4.48 (20.7) In a post-natal extension state (pre or post waiver)20.5 (40.3) Simulated Income Eligibility, in waiver state24.0 (42.7) Simulated Income Eligibility, in comparison states6.62 (24.8) Simulated Extension Eligibility, in waiver states12.12 (24.9) Simulated Extension Eligibility, in comparison states 22.6 (41.8) Fraction of Sample Post-waiver years, all states 77.4 (41.8) N 23,583

16 Waiver/Comparison States Characteristics Variable Waiver StatesComparison States Fathers High Grade Completed 12.5 (3.18)12.8 (3.06) Ratio Gross Income to Federal Poverty Level 294.6 (3.00)305.0 (3.22) Black 31.6 (46.49)21.7 (41.25) Hispanic 23.3 (42.47)16.2 (36.82) Year of First Sex 1999 (3.08)1999 (3.15) Ever had Sex 74.1 (43.73)74.1 (44.74) Sex since last survey 49.25 (50.00)48.81 (49.99) Used BC, last sex 73.1 (44.37)73.2 (44.28) Pregnant, last year 15.7 (36.38)15.9 (36.57) Pregnancy, no live birth 9.8 (29.74)9.8 (29.70) Pregnancy risk, usual BC 13.79 (25.3)13.78 (28.7) Pregnancy risk, usual BC, sexually active 21.6 (36.2)21.5 (40.9) Age 19.3 (3.12)19.2 (3.15) Urban 84.2 (43.50)80.2 (47.92) Medicaid Eligible 23.3 (42.25)21.1 (40.78) N 13,18010,413

17 DDD Results OLSFixed Effects Outcome DDDStd ErrR2R2 DDDStd ErrR2R2 N# persons Any Type of Family Planning Waiver Pregnant in past year a -0.1480.022*0.26-0.1320.024*0.19234374314 Gave Birth in past year a -0.05050.013*0.12-0.04620.016*0.08234374314 Pregnancy & non-live birth a -0.0970.17*0.16-0.0860.019*0.16234374314 Sexually Active in past year a -0.0680.033*0.30-0.0500.0290.30189554274 Pregnancy Risk, usual BC method 0.7241.870.0690.00360.00240.07177854141 Used BC last sex a 0.0200.0630.034-0.0170.084.02560732903 Percent sexual intercourse used BC 5.134.110.0839.884.310.06114793377 Source: Authors calculations from 1997 NLSY. Regressions also control for state, sample year, age, menses, Medicaid eligibility, and urbanicity. Standard errors corrected for clustering at individual level. *, Statistically significant at the 1%, 5% level. a. Standard errors corrected for heteroskedasticity in linear probability models.

18 DDD Results, contd Source: Authors calculations from 1997 NLSY. Regressions also control for state, sample year, age, menses, Medicaid eligibility, and urbanicity. Standard errors corrected for clustering at individual level. *, Statistically significant at the 1%, 5% level. a. Standard errors corrected for heteroskedasticity in linear probability models.

19 DDD Results, contd Source: Authors calculations from 1997 NLSY. Regressions also control for state, sample year, age, menses, Medicaid eligibility, and urbanicity. Standard errors corrected for clustering at individual level. *, Statistically significant at the 1%, 5% level. a. Standard errors corrected for heteroskedasticity in linear probability models.

20 General Results Decreases sexual activity Decreases sexual activity Decreases probability of pregnancy, giving birth, & combined abortion, miscarriages & stillbirth Decreases probability of pregnancy, giving birth, & combined abortion, miscarriages & stillbirth –Large, statistically significant effects –Greater relative impact on combined abortion, miscarriages & stillbirth than on giving birth Extension waivers have larger impact Extension waivers have larger impact No measured impact on contraceptive outcomes No measured impact on contraceptive outcomes

21 Robustness Checks Dropping pre-1997 waiver states Dropping pre-1997 waiver states –Income eligibility waivers have negative, statistically significant impact on pregnancy & giving birth –Extension waivers impact same magnitude except in FE (drops to match OLS results) Dropping nonwhites increases estimates of efficacy Dropping nonwhites increases estimates of efficacy Separate examination compared to Medicaid eligible, other control group Separate examination compared to Medicaid eligible, other control group –More effective relative to Medicaid eligible control, stronger impacts FE similar to OLS, except for extension waivers FE similar to OLS, except for extension waivers WLS estimates slightly smaller than OLS/FE WLS estimates slightly smaller than OLS/FE

22 Teens No statistically significant impact on sexual activity No statistically significant impact on sexual activity Any-type waiver decreases teen pregnancy, motherhood, combined abortion, miscarriage & still births Any-type waiver decreases teen pregnancy, motherhood, combined abortion, miscarriage & still births Income eligibility waivers decrease pregnancy, teen mother hood Income eligibility waivers decrease pregnancy, teen mother hood Extension waivers decrease teen pregnancy Extension waivers decrease teen pregnancy

23 Rural/Urban Differences

24 Future Directions BC consistency of use sensitive to outliers? BC consistency of use sensitive to outliers? More work on unplanned/unwanted pregnancy More work on unplanned/unwanted pregnancy Other pregnancy outcomes (spacing, prenatal care, low birth weight / premature birth) Other pregnancy outcomes (spacing, prenatal care, low birth weight / premature birth) Males Males Other aspects of policy (enrollment practices etc…) Other aspects of policy (enrollment practices etc…) Older women Older women Other reproductive health policies, provider availability (addition of Guttmacher Institute data) Other reproductive health policies, provider availability (addition of Guttmacher Institute data) Cost-benefit ratios Cost-benefit ratios

25 Conclusions Effective at reducing pregnancies, combined abortions, miscarriages & stillbirths, bigger effects for teens Effective at reducing pregnancies, combined abortions, miscarriages & stillbirths, bigger effects for teens No increased sexual activity No increased sexual activity Results apply to all eligible young women, not just participants Results apply to all eligible young women, not just participants Robust to sampling assumptions Robust to sampling assumptions DDD + fixed effects provide strong support for waivers DDD + fixed effects provide strong support for waivers


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