Medicaid reimbursement, prenatal care and infant health

Patients' Perspectives on Informational Support and Education in the Perinatal Period: "The Quicker They Could Be Done With Me, the Better"

INTRODUCTION

The overall purpose of this study was to elicit perspectives from a diverse group of postpartum individuals about their perinatal outpatient informational support and education. In addition, suggestions from participants are provided. Although informational support is crucial in the peripartum period, it is often inadequate or biased. Qualitative research, which offers a nuanced and patient-centered perspective, is limited. The qualitive research that does exist is limited to the prenatal period only, neglecting perspectives throughout the entire peripartum period.

METHODS

This qualitative descriptive study was part of a larger observational cross-sectional study of postpartum individuals in Kalamazoo, Michigan in 2017. Two years after the initial study (2019), participants were recruited into 8 focus groups. Trained facilitators guided focus group conversations using semistructured interview questions. The questions centered on overall experiences with perinatal outpatient health care experiences and informational support. Thematic analyses were used in data analysis. Interrater reliability between coders ranged from 92% to 100%.

RESULTS

Fifty-four individuals (22.1% response rate) participated in a total of 12 focus groups. The overarching theme was the need for recognition of individuality of patients. Three subthemes emerged, including time, multiple modalities of information support, and agency.

DISCUSSION

This study extended previous qualitative findings across the entire peripartum period and that individualized prenatal care is an important distinction in perceived quality of care. Health care organizations should consider allocating time differently for perinatal office visits, offer flexible visit times based on individualized needs, offer information in multiple modalities, and promote agency of patients. This study was strengthened by the community involvement, women of color only focus groups, and oversampling of Black women. This study was limited by the self-selected, homogenous sample and potential for recall bias.

Long-run intergenerational health benefits of women empowerment: Evidence from suffrage movements in the US

An ongoing body of research documents that women empowerment is associated with improved outcomes for children. However, little is known about the long-run effects on health outcomes. This paper adds to this literature and studies the association between maternal exposure to suffrage reforms and children's old-age longevity. We utilize changes in suffrage laws across US states and over time as a source of incentivizing maternal investment in children's health and education. Using the universe of death records in the US over the years 1979-2020 and implementing a difference-in-difference econometric framework, we find that cohorts exposed to suffrage throughout their childhood live 0.6 years longer than unexposed cohorts. Furthermore, we show that these effects are not driven by preexisting trends in longevity, endogenous migration, selective fertility, and changes in the demographic composition of the sample. Additional analysis reveals that improvements in education and income are candidate mechanisms. Moreover, we find substantial improvements in early-adulthood socioeconomic standing, height, and height-for-age outcomes due to childhood exposure to suffrage movements. A series of state-level analyses suggest reductions in infant and child mortality following suffrage law change. We also find evidence that counties in states that passed the law experienced new openings of County Health Departments and increases in physicians per capita.

The impact of access to prenatal health insurance for noncitizen women on child health

OBJECTIVE

To estimate the effects of prenatal public health insurance targeting noncitizens on the health of U.S.-born children of noncitizen mothers beyond birth outcomes.

DATA SOURCES AND STUDY SETTING

This paper uses the restricted version of the 1998-2014 National Health Interview Survey with state-level geographic identifiers.

STUDY DESIGN

The empirical strategy compares outcomes in states that adopted the Children's Health Insurance Plan (CHIP) Unborn Child Option with states that never adopted or adopted it at different times, controlling for differences in the pre-treatment period. I use a flexible event-study analysis to quantify the effects of the Unborn Child Option on noncitizen women's health insurance coverage, health care utilization, and their children's health.

DATA COLLECTION/EXTRACTION METHODS

All data are derived from pre-existing sources.

PRINCIPAL FINDINGS

The study finds that the impact of the Unborn Child Option is a 4.7%-point increase in public health insurance coverage (p < 0.01) and 0.48 more doctor's office visits (p < 0.1) annually among noncitizens of childbearing ages. Subsequently, the reform leads to a 7%-point rise in the rate of parents reporting their 4-6-year-old children are in "excellent" or "very good" health (p < 0.01). While no improvements are evident at birth and at younger ages, observed health improvements begin to appear by preschool age.

CONCLUSIONS

The study contributes to the literature by providing evidence that certain benefits of in-utero public health insurance targeting noncitizens may appear several years after birth, specifically around preschool age.

Newborns during the crisis: Evidence from the 1980s' farm crisis

The sudden and jumping interest rate in the early 1980s triggered a severe economic crisis in the US agriculture sector. To identify the effects of wealth losses on the health condition of cohorts born in the midst of the crisis, this paper constructs an instrumental variable for wealth by exploiting the geographic variation in crop production and the timing of the shock. This study finds that wealth losses generates long-lasting health impacts for these newborns. A one percent wealth loss leads to an approximately 0.008 and 0.003 percentage point increase in the low and very low birth weight rates, respectively. In addition, cohorts growing up in areas of greater impacts have worse self-reported health condition before age 17 than others. They also have more metabolic-syndrome issues and smoke more regularly than other cohorts in adulthood. Lower expenditures on food and prenatal care might explain the negative health effects on cohorts born during the crisis. The study shows that households in areas with greater wealth losses have more declining expenditures on food at home and prenatal-care doctor visits.

Medicaid and the Children's Health Insurance Program: an overview for the pediatric radiologist

In terms of number of beneficiaries, Medicaid is the single largest health insurance program in the US. Along with the Children's Health Insurance Program (CHIP), Medicaid covers nearly half of all births and provides health insurance to nearly half of the children in the country. This article provides a broad introduction to Medicaid and CHIP for the pediatric radiologist with a special focus on topics relevant to pediatric imaging and population health. This includes an overview of Medicaid's structure and eligibility criteria and how it differs from Medicare. The paper examines the means-tested programs within the context of pediatric radiology, reviewing pertinent topics such as the rise of Medicaid managed care plans, Medicaid expansion, the effects of Medicaid on child health, and COVID-19. Beyond the basics of benefits coverage, pediatric radiologists should understand how Medicaid and CHIP financing and reimbursement affect the ability of pediatric practices, radiology groups, and hospitals to provide services for children in a sustainable manner. The paper concludes with an analysis of future opportunities for Medicaid and CHIP.

COVID-19 and Indigenous health in the Brazilian Amazon

We test whether the COVID-19 pandemic has an ethnicity-differentiated (Indigenous vs non-Indigenous) effect on infant health in the Brazilian Amazon. Using vital statistics data we find that Indigenous infants born during the pandemic are 0.5% more likely to have very low birth weights. Access to health care contributes to health gaps. Thirteen percent of mothers travel to deliver their babies. For traveling mothers, having an Indigenous baby during the pandemic increases the probability of very low birth weight by 3%. Indigenous mothers are 7.5% less likely to receive adequate prenatal care. Mothers that travel long distances to deliver their babies and give birth during the pandemic are 35% less likely to receive proper prenatal care. We also find evidence that the pandemic shifts medical resources from rural to urban areas, which disproportionately benefits non-Indigenous mothers. These results highlight the need for policies to reduce health inequalities in the Amazon.

Maternal human capital and infants' health outcomes: Evidence from minimum dropout age policies in the US

The purpose of this cross-sectional study is to examine the causal relationship of maternal education and infants' health outcomes. Using birth certificate data over the years 1970–2004 and exploiting the space-time variation in Minimum Dropout Age laws to solve the endogeneity of education, we find a sizeable effect of mothers' education on their birth outcomes. An additional year of maternal education is associated with a reduction in incidences of low birth weight and preterm birth by 15.2 and 12.7 percent, respectively. The estimates are robust across various specifications and even when allowing mothers’ cohort-of-birth to vary across regions. The results suggest that the candidate mechanisms of impact include improvements in timing, quantity, and quality of prenatal care, lower negative health behavior during pregnancy such as smoking and drinking, and higher spousal education.

•

We provide causal evidence on the effect of mothers' education on birth outcomes.

•

We use Minimum Dropout Age policies as the instrument.

•

Mother education has significant impact on infants' birth outcomes.

•

Candidate mechanisms include improvements in timing, quantity, and quality of prenatal care.

Patterns of peripartum depression screening and detection in a large, multi-site, integrated healthcare system

The purpose of this study was to examine peripartum depression (PD) screening patterns within and across the prenatal and postpartum periods and assess the incidence of new positive screens during standard screening protocol timepoints to inform practice, particularly when limited screenings can be conducted.This is a retrospective observational study of women screened for PD through a large, integrated health system using the Edinburgh Postnatal Depression Scale (EPDS) within their obstetrics and pediatric practices. Pregnancies with an EPDS score for at least one obstetric and one pediatric appointment between November 2016 and October 2019 were included (n = 3240). The data were analyzed using chi-squared test, Student's t-test, and binary logistic regression analyses. An EPDS score of 10 or higher was considered a positive screen.The positive screening rate for this cohort was 18.5%, with a prenatal positive rate of 9.9% and a postpartum positive rate of 8.6%. Single relationship status showed a higher rate of PD overall. Two thirds of women were not screened until their third trimester, resulting in delayed detection for an estimated 28% of women who ultimately screened positive. Few new positive screens (1.3%) were detected after 9 weeks postpartum in women who had completed all recommended prior screens.Obstetric providers should screen for PD as early in pregnancy as possible and continue to screen as often as feasible regardless of previous negative EPDS scores. Prioritizing screening more often in pregnancy and before 9 weeks postpartum is optimal to avoid delays in detection and intervention.

A systematic review of the qualitative literature on barriers to high-quality prenatal and postpartum care among low-income women

OBJECTIVE

To examine the qualitative literature on low-income women's perspectives on the barriers to high quality prenatal and postpartum care.

DATA SOURCES AND STUDY SETTING

We performed searches in PubMed, Web of Science, Embase, SocIndex, and CINAHL for peer-reviewed studies published between 1990 to 2021.

STUDY DESIGN

Systematic review of qualitative studies with participants who were currently pregnant or had delivered within the past two years and identified as low-income at delivery.

DATA COLLECTION / EXTRACTION METHODS

Two reviewers independently assessed studies for inclusion, evaluated study quality, and extracted information on study design and themes.

PRINCIPLE FINDINGS

We identified 34 studies that met inclusion criteria, including 23 focused on prenatal care, 6 on postpartum care, and 5 on both. The most frequently mentioned barriers to prenatal and postpartum care were structural. These included delays in gaining pregnancy-related Medicaid coverage, challenges finding providers who would accept Medicaid, lack of provider continuity, transportation and childcare hurdles, and legal system concerns. Individual-level factors, such as lack of awareness of pregnancy, denial of pregnancy, limited support, conflicting priorities, and indifference to pregnancy also interfered with timely use of prenatal and postpartum care. For those who accessed care, experiences of dismissal, discrimination, and disrespect related to race, insurance status, age, substance use, and language were common.

CONCLUSIONS

Over a period of 30 years, qualitative studies have identified consistent structural and individual barriers to high-quality prenatal and postpartum care. Medicaid policy changes including expanding presumptive eligibility, increased reimbursement rates for pregnancy services, payment for birth doula support, and extension of postpartum coverage may help overcome these challenges.

The effects of incentivizing early prenatal care on infant health

We investigate the effects of incentivizing early prenatal care utilization on infant health by exploiting a reform that required expectant mothers to initiate prenatal care during the first ten weeks of gestation to obtain a one-time monetary transfer paid after childbirth. Applying a difference-in-differences design to individual-level data on the population of births and fetal deaths, we identify modest but statistically significant positive effects of the policy on neonatal health. We further provide suggestive evidence that improved maternal health-related knowledge and behaviors during pregnancy are plausible channels through which the reform might have affected fetal health.

Intergenerational health effects of Medicaid

This paper investigates the effects of the introduction of Medicaid during the 1960s on next generations' birth outcomes. A federal mandate that all states must widen the coverage to all cash welfare recipients generated cross-state variations in Medicaid eligibility, specifically among nonwhites who largely overrepresented the target population. I implement a reduced-form difference-in-differences strategy that compares the birth outcomes of mothers born in states with higher cash welfare recipiency versus low welfare recipiency and different years relative to the Medicaid implementation year. Using Natality data (1970-2004), I find that Medicaid significantly improves birth outcomes. The effects are considerably larger among nonwhites, specifically blacks. The effects do not appear to be driven by preexisting trends in birth outcomes, preexisting trends in households' socioeconomic characteristics, changes in other welfare expenditures, and selective fertility. A back-of-an-envelope calculation points to a minimum of 3.9% social externality of Medicaid through income rises due to next generations' improvements in birth outcomes.

Medicaid Cost and Reimbursement for Low-Risk Prenatal Care in the United States

INTRODUCTION

We calculate the financial margins for delivery of routine antenatal care as reimbursed by Medicaid. Prenatal care cost varies with overhead, health care provider type, and number of office visits. Antenatal care is only one component of the global maternity bundle, which also includes intrapartum and postpartum care.

METHODS

Time for provision of low-risk antenatal care was determined prospectively from a study of 133 low-risk pregnant patients. Health care provider time cost was estimated using mean wages for obstetricians and midwives. Margins were estimated by subtracting cost of provider services and overhead for the antenatal component of maternity care from total Medicaid reimbursement for the pregnancy global package (CPT 59400) using 2015 dollars. The maternity bundle elements of routine prenatal laboratory tests, ultrasounds, intrapartum care, and postpartum care were not included in our analysis of cost components.

RESULTS

Patients received an average of 215 minutes of direct provider time per pregnancy. At the 50th percentile for physician payment and assuming overhead is 53.4% of revenue, practice margins varied by state from -$1067 to +$675, with a median of -$357. Median margins for midwifery care were +$15, with a range of -$579 to +$885. Margins were negative if overhead costs exceeded 33% of revenue for physician care and 55% of revenue for midwifery care.

DISCUSSION

In many states, Medicaid reimbursement for the global maternity package is less than the actual cost of antenatal care alone. Improving reimbursement or decreasing costs is necessary to make maternity care more cost-effective.

Territorial differences in access to prenatal care and health at birth

We assess the impact of prenatal care on health at birth using birth certificates from the Czech Republic. We use a predictive machine learning algorithm to identify the observables affecting birth health outcomes. We control for those observables in our empirical analysis, which indicates that a more intense use of prenatal care is positively correlated with better health outcomes at birth. Exploiting the Czech adhesion to the EU in 2004, we construct an instrument to capture the geographical heterogeneous access to prenatal care across districts. Differently from the OLS results, the IV results do not capture any significant effect of prenatal care, leaving room for the hidden role of unobservable mothers' characteristics when it comes to health behaviors during pregnancy.

Babies and Bandidos: Birth outcomes in pacified favelas of Rio de Janeiro

This paper explores police operations "pacifying" Rio de Janeiro's favelas to estimate if positive shocks of policing affect birth outcomes. Estimates show that pregnancies residing within official "pacification" borders had 0.07 standard deviation better birth outcomes than pregnancies on the same street but giving birth shortly before the police's arrival. Pacification effects concentrate in the third trimester of gestation and are followed by increases in the number of prenatal visits. No evidence of spillovers is found in areas immediately circumventing pacification borders. Hospital-level estimates indicate no impacts on the supply of health services, stress/anxiety among women, or abortions.

Changes needed in Medicaid coverage and reimbursement to meet an evolving abortion care landscape

Medicaid is the largest publicly funded health insurance program in the United States, covering 76 million individuals as of August 2020. Research shows that Medicaid improves health and healthcare access on a variety of indicators. Abortion is a common reproductive health service in the United States. However, Medicaid coverage of abortion varies by state; with 34 states and the District of Columbia limiting themselves to a federal policy that only permits coverage under cases of incest, rape, or life endangerment. With 75% of abortion patients earning low incomes, Medicaid coverage of this service is particularly salient to abortion access. In this commentary, we describe the complexities of Medicaid coverage and reimbursement of abortion in the United States and the implications of this complexity. Further, we consider the potential impact of changes in abortion provision, including increasing provision of medication abortion and the use of healthcare delivery models such as telemedicine for medication abortion, on Medicaid coverage and reimbursement. Finally, we provide a few policy and practice recommendations for abortion coverage now and in the future.

Going the distance: Associations between adverse birth outcomes and obstetric provider distances for adolescent pregnancies in South Carolina

PURPOSE

Distances to obstetric care providers are a persistent concern, especially for rural pregnant adolescents. Births to adolescents are disproportionately affected by adverse birth outcomes (ABOs), yet little is known regarding how driving distances may impact ABOs. This study examines the association between driving distances to obstetric providers and ABOs among adolescent mothers in South Carolina.

METHODS

This retrospective cross-sectional study derived ZIP Code-level birth statistics from mothers aged 10-19 in South Carolina using 2013-2017 statewide birth certificate data. ABOs included preterm birth and/or low birthweight. Provider distance was calculated between an obstetric provider's ZIP Code tabulated area (ZCTA) centroid and a maternal resident's ZCTA centroid. Descriptive statistics and weighted generalized linear regression were conducted.

RESULTS

Mean provider distances to obstetric providers were similar between urban (11.76 miles) and rural adolescent mothers (12.04 miles). An increase in provider distance, on average, was associated with a decrease in ABO rates (-0.79, p= .0038); however, rural-urban differences were found. Living in a rural ZCTA was associated with a decrease in ABOs (4.94%, p = .0043). Urban ZCTAs showed a U-shaped association with provider distance, with ABO rates decreasing until approximately 17 miles away from a provider and then increasing.

CONCLUSION

Rural adolescent mothers with greater distance to providers had lower ABO rates, while, in urban ZCTAs, provider distance over 17 miles was associated with higher ABO rates. Understanding what mitigates the effects of driving distance on ABOs in rural South Carolina would help inform future policy planning in underserved communities.

Preconception subsidized insurance: Prenatal care and birth outcomes by race/ethnicity

Low-income pregnant women have been Medicaid eligible since the 1980s, but the Affordable Care Act (ACA)'s expansion of Medicaid to women preconception has the potential to improve pregnancy and birth outcomes by removing delays in Medicaid enrollment. More substantially, the ACA expanded subsidized nongroup maternity coverage. Pre-ACA, nongroup health insurance had generally excluded maternity coverage and was prohibitively expensive for low-income individuals, but the ACA's creation of the Marketplace made maternity coverage mandatory and provides income-based subsidies. I use a simulated eligibility approach to measure how these two aspects of the ACA impacted pregnancy and birth outcomes for first-time mothers, paying special attention to racial-ethnic differences. I find expanding Medicaid to women prior to pregnancy significantly improves the share of women with a prenatal care visit in the first trimester for non-Hispanic Whites and Blacks. Expansions in non-Medicaid subsidized insurance, such as Marketplace insurance, significantly reduce the share of births paid by Medicaid and increased breastfeeding across all racial and ethnic groups. Neither type of subsidized insurance had significant, robust impacts on birth outcomes.

The effect of prenatal maternity leave on short and long-term child outcomes

Maternity leave policies are designed to safeguard the health of pregnant workers and their unborn children. We evaluate a maternity leave extension in Austria which increased mandatory prenatal leave from 6 to 8 weeks. We exploit that the assignment to the extended leave was determined by a cutoff date. We find no evidence for significant effects of this extension on children's health at birth or long-term health and labor market outcomes. Subsequent maternal health and fertility are also unaffected. We conclude that employment during the 33rd and 34th week of gestation is not harmful for expecting mothers (without major problems in pregnancy) and their unborn children.

Improving the Experience of Care: Results of the American Association of Birth Centers Strong Start Client Experience of Care Registry Pilot Program, 2015-2016

In 2018, the Center for Medicare and Medicaid Innovation in the United States (US) released report demonstrating birth centers as the appropriate level of care for most Medicaid beneficiaries. A pilot project conducted at 34 American Association of Birth Centers (AABC) Strong Start sites included 553 beneficiaries between 2015 and 2016 to explore client perceptions of high impact components of care. Participants used the AABC client experience of care registry to report knowledge, values, and experiences of care. Data were linked to more than 300 process and outcome measures within the AABC Perinatal Data Registry™. Descriptive statistics, t tests, χ analysis, and analysis of variance were conducted. Participants demonstrated high engagement with care and trust in pregnancy, birth, and parenting. Beneficiaries achieved their preference for vaginal birth (89.9%) and breastfeeding at discharge through 6 weeks postpartum (91.7% and 87.6%). Beneficiaries reported having time for questions, felt listened to, spoken to in a way they understood, being involved in decision making, and treated with respect. There were no variations in experience of care, cesarean birth, or breastfeeding by race. Medicaid beneficiaries receiving prenatal care at AABC Strong Start sites demonstrated high levels of desired engagement and reported receiving respectful, accessible care and high-quality outcomes. More investment and research using client-reported data registries are warranted as the US works to improve the experience of perinatal care nationwide.

Association of Medicaid Expansion With Coverage and Access to Care for Pregnant Women

OBJECTIVE

To identify the association of the Affordable Care Act's Medicaid expansion with payment for delivery, early access to prenatal care, preterm birth, and birth weights considered small for gestational age (SGA).

METHODS

A difference-in-difference design was used to assess changes in outcomes before and after Medicaid expansion in expansion states, using nonexpansion states as a control group. We used national birth certificate data from 2009 to 2017. Difference-in-difference linear probability models were used to assess the effects of the policy implementation, adjusting for demographics, month of birth, state, year, and county-level unemployment rates. Standard errors were clustered at the state level. Two prespecified subgroup analyses were performed of nulliparous women and women with no more than a high school diploma.

RESULTS

The study sample included 8,701,889 women from 15 expansion states and 9,509,994 from 11 nonexpansion states. In the adjusted analysis, the percentage of Medicaid-covered deliveries increased by 2.3 absolute percentage points (95% CI 0.2-4.4, P=.04) in expansion states compared with nonexpansion states. There were no significant changes in the proportion of women who were uninsured, as there was a relative decrease in the percentage of deliveries covered by private insurance (-2.8 percentage points [95% CI -4.9 to -0.8, P=.01]). There were also no significant differences in the rate of women initiating prenatal care in the first trimester, preterm birth rates, or rates of low birth weight after the Medicaid expansion. Findings were similar in both subgroups.

CONCLUSION

Medicaid expansion was associated with increased Medicaid coverage for childbirth in expansion states; similar gains in private coverage were seen in nonexpansion states. There were no associations with changes in early access to prenatal care, preterm birth, or SGA birth weights.

Exploring the social determinants of racial/ethnic disparities in prenatal care utilization and maternal outcome

Rates of maternal morbidity and mortality are rising in the United States. Non-Hispanic Black women are at highest risk for these outcomes compared to those of other race/ethnicities. Black women are also more likely to be late to prenatal care or be inadequate users of prenatal care. Prenatal care can engage those at risk and potentially influence perinatal outcomes but further research on the link between prenatal care and maternal outcomes is needed. The objective of this article is to review literature illuminating the relationship between prenatal care utilization, social determinants of health, and racial disparities in maternal outcome. We present a theoretical framework connecting the complex factors that may link race, social context, prenatal care utilization, and maternal morbidity/mortality. Prenatal care innovations showing potential to engage with the social determinants of maternal health and address disparities and priorities for future research are reviewed.