1. The Forgotten Beneficiary of the Medicaid Expansions Andrea Kutinova and Karen Smith Conway Department of Economics University of New Hampshire

2. 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.”

3. 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

4. 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)

5. 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

6. 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

7. 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)

8. Descriptive Statistics – PNC Utilization  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)

9. Descriptive Statistics – Maternal Health  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

10. 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”

11. 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

12. 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

13. 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

14. Questions and Comments Appreciated kutinova@cisunix.unh.edu