Research Results and Policy Context: Pregnant and Poor: Did Medicaid and Welfare Policy Changes Improve Care for these Women as Intended?

Research Results and Policy Context

Research Results

Genevieve Kenney, Ph.D. – Urban Institute – and colleagues¹ studied the impact of the move to Medicaid managed care on prenatal care and birth outcomes nationally and in two states. E. Kathleen Adams, Ph.D. – Emory University – and colleagues²examined whether low-income women are less likely to be insured prior to and during pregnancy as a result of the Personal Responsibility and Work Opportunity Reconciliation Act’s (PRWORA) de-coupling of cash assistance from Medicaid and whether decreased Medicaid enrollment due to PRWORA resulted in delayed prenatal care.

Kenney and colleagues found that the effects of Medicaid managed care on prenatal care were mixed, depending on state specific environments and differences in implementation. A key finding was that managed care was associated with reductions in smoking during pregnancy, but that rates of smoking among Medicaid-covered women remained high. Their research also confirmed earlier work showing that Medicaid eligibility and coverage expansions for pregnant women promoted earlier prenatal care. However, neither managed care nor coverage expansions had any measurable positive effect on birth outcomes. Adams found that even prior to PRWORA (welfare reform) pregnant women experienced more transition and change in insurance status than anticipated and the end result of PRWORA was that more low-income women were uninsured prior to pregnancy. The study provided evidence that welfare reform led to less take-up and delayed take-up of Medicaid benefits. Adams and colleagues also simulated a variety of potential policy reforms and found that the intervention most likely to have an effect on early prenatal care and, potentially, birth outcomes would be an expansion of private insurance for low-income women prior to pregnancy.

Both of these studies support the contention that the timing of Medicaid enrollment is critical, and policy interventions promoting earlier insurance coverage for pregnant women could have a beneficial effect on initiation of prenatal care and, potentially, birth outcomes. The need to confirm a pregnancy and the finite period of pregnancy limit the potential of the Medicaid expansions and other Medicaid interventions to affect outcomes. This limitation may be compounded by the fact that health status at the time of pregnancy and one’s desire to be pregnant are factors that have been associated with the timing of prenatal care,^{3, 4} although the findings regarding adverse outcomes are not consistent.⁵

Policy Context

The policy discussion began with a moderated discussion with Debbie Chang, currently at the National Academy of State Health Policy and formerly Maryland’s Medicaid Director, and Rachel Benson Gold of the Alan Guttmacher Institute. Chang and Gold reacted to the research findings, placing them in a “real world” context. They then discussed whether the research results reflect the experience of those working in the states and the affected populations. They also discussed the implications of the findings for policy and operations and identified additional questions to which state officials need answers. Following the moderated discussion, participants in the Cyber Seminar were able to ask questions and make comments of their own by phone or through the virtual chat room.

____________________________
1 Lisa Dubay, ScM, (Co-Principal Investigator), Principal Research Associate, The Urban Institute; Embry Howell, Ph.D., Principal Research Associate, The Urban Institute; Anna Sommers, M.A. Research Associate, The Urban Institute; and Robert Kaestner, Ph.D. Professor, Department of Economics and Institute of Government and Public Affairs, The University of Illinois at Chicago.

2 Norma I.Gavin, Ph.D., Director of Maternal, Child and Reproductive Health Program at the Research Triangle Institute; Arden Handler, Dr.Ph., Community Health Sciences, School of Public Health, University of Chicago at Illinois; Will Manning, Ph.D., Professor, Department of Health Studies, University of Chicago; and Cheryl Raskind-Hood, M.P.H., Research Professor, Rollins School of Public Health.

3 Centers for Disease Control and Prevention, Unintended Childbearing: Pregnancy Risk Assessment Monitoring System-Oklahoma, 1988-1991. Mortality and Morbidity Weekly Report (MMWR), Volume 41, 1992.

4 Kost, K., Landry, D.J., and Darroch, J.E., Predicting Maternal Behaviors During Pregnancy: Does Intention Status Matter? Family Planning Perspectives, Volume 30, No. 2, Alan Guttmacher Institute, March/April 1998.

5 Colley-Gilbert B., Brantley, M.D., Larson, M.K., Family Planning Practices and Pregnancy Intention, 1997. Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 2000.
______________________________________

Overview
Research Results and Policy Context
Presenters and Discussants
Download Presenters' Slides
Download and Watch the Cyberseminar (ZIP file, 17.5 MB)