C
Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants1

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This appendix provides brief synopses of the studies that were reviewed for and presented in Chapter 6. The table is organized according to the four major sections in Chapter 6: “Access to and Use of Health Care by Children,” “Health Outcomes for Children and Youth,” “Effect of Health on Children’s Life Chances,” and “Prenatal and Perinatal Care and Outcomes,” Studies are listed alphabetically within each section.



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Health Insurance is a Family Matter C Research Review: Health Care Access, Utilization, and Outcomes for Children, Pregnant Women, and Infants1 1   This appendix provides brief synopses of the studies that were reviewed for and presented in Chapter 6. The table is organized according to the four major sections in Chapter 6: “Access to and Use of Health Care by Children,” “Health Outcomes for Children and Youth,” “Effect of Health on Children’s Life Chances,” and “Prenatal and Perinatal Care and Outcomes,” Studies are listed alphabetically within each section.

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Health Insurance is a Family Matter   Sample Size/ Data Source Outcome Measures Access to and Use of Health Care by Children Aday (1992) Health Insurance and Utilization of Medical Care for Chronically Ill Children with Special Needs. Advance Data Data from the NHIS Child Health (CH) Supplement, 1998 Chronic illness and special needs children Aday et al. (1993) Health Insurance and Utilization of Medical Care for Children with Special Health Care Needs. Medical Care Data from 1988 NHIS, Child Health Supplement; 9.6 million U.S. children with special health care needs Utilization of physicians, hospitals, and prescribed medicine Bindman et al. (1995) Preventable Hospitalizations and Access to Health Care. JAMA Data from California hospital discharge records; 6,674 English- and Spanish-speaking adults aged 18–64 Reports of access to medical care Brown et al. (1999) Access to Health Insurance and Health Care for Children in Immigrant Families. In Children of Immigrants: Health, Adjustment, and Public Assistance March 1996 CPS survey and 1994 NHIS (n = 35,600 children 0–17 and n = 32,000 children 0–17, respectively) Access to health care services; health insurance coverage; and citizenship status

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Health Insurance is a Family Matter Findings The highest-prevalence conditions included in the 1988 NHIS-CH included hay fever and respiratory allergies, frequent or repeated ear infections, and asthma. About 9.6 million children under 18 years of age were estimated to have special needs: 76% of the children had insurance coverage, 11% had Medicaid, and 13% had neither. Black and Hispanic children were two times as likely to be uninsured. The proportion of uninsured children who had seen a physician was lower than the proportion of those with private insurance. There is substantial variation in access to routine medical care among these children. In general, poor minority children living with their mothers or someone other than their parents, or those without insurance or a regular medical provider, were more likely to experience financial barriers to access or less apt to seek care than other children with comparable needs. Children with Medicaid coverage were more than three times as likely to see a doctor than those who were uninsured. Those who were insured as well as those who had coverage that was not known were more likely to be hospitalized than the uninsured. Access to care was inversely associated with hospitalization rates for the five chronic medical conditions (asthma, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and diabetes). Self-rated access to care and the prevalence of the condition remained independent predictors of cumulative hospitalization rates for chronic medical conditions. Communities where people perceive they have poor access to medical care have higher rates of hospitalization for chronic diseases. Improving access to care is more likely to reduce hospitalization rates for chronic conditions than changing patients’ propensity to seek care or eliminating variations in physician practice style. The immigration status of both the child and the primary breadwinning parent has an independent effect on the child’s risk of uninsurance, even controlling for the parent’s educational attainment and residency of 10 years or more. Non-citizen children have the greatest risk of being uninsured. Non-citizen Latino and Asian children have a higher risk of being uninsured than their U.S.-born counterparts or white children with U.S.-born parents. U.S. citizen children with immigrant parents have a greater risk of uninsurance than those with U.S.-born parents. These children have an even greater risk if their families immigrated on or after 1984. Uninsured rates are higher among children in immigrant families from Korea and Central America than those from other regions. Immigrant children and U.S.-born children with immigrant parents are more likely to have difficulty accessing health care services than nonimmigrant children. Immigrant children are less likely to have had a physician visit in the past year than nonimmigrant children. For those who have insurance (immigrant children and citizen children), the disparities are not large: 43% of uninsured immigrant children report having no physician visit in the last 12 months, compared to 28% of immigrant children with private coverage and 16% with Medicaid.

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Health Insurance is a Family Matter   Sample Size/ Data Source Outcome Measures Byck (2000) A Comparison of the Socioeconomic and Health Status Characteristics of Uninsured, State Children’s Health Insurance Program-Eligible Children in the United States with Those of Other Groups of Insured Children: Implications for Policy. Pediatrics Data for 50,950 children 0–8 years of age included in the 1993 and 1994 NHIS Socioeconomic and demographic characteristics of children Currie and Duncan (1995) Medical Care for Children: Public Insurance, Private Insurance, and Racial Differences in Utilization. J Hum Resources Child–mother module of National Longitudinal Survey of Youth; longitudinal data from 1986 and 1988 waves for children born between 1979 and 1985, repeated observations for same child Physician checkups; physician illness visits Currie and Gruber (1996b) Health Insurance Eligibility, Utilization of Medical Care, and Child Health. Quarterly Journal of Economics NHIS sample of children <15; 30,000 each year between 1984 and 1992; CPS for Medicaid coverage rates and eligibility Any ambulatory visits in year; recent visit; hospitalizations in year; site of care; mortality Currie (2000) Do Children of Immigrants Make Differential Use of Public Health Insurance? In Issues in the Economics of Immigration NHIS sample of children <15; 1989–1992 Insurance coverage; probability of no visits in past year; number of physician visits annually; hospitalizations annually Dubay and Kenney (2001) Health Care Access and Use Among Low-Income Children: Who Fares Best? Health Affairs Data from the 1997 NSAF; sample: 12,680 low-income (<200% FPL) children Access to care and use of services based on insurance coverage

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Health Insurance is a Family Matter Findings Children in SCHIP differ socioeconomically and by health status from those on Medicaid and those that are privately insured (however, they differ to a lesser extent from those that are privately insured). SCHIP children live with college-educated individuals (39.4%) and employed adults (91.2%) versus 23% and 53.9%, respectively, for Medicaid children and 66.7% and 96.9% for those privately insured. Parents of SCHIP children are disproportionately self-employed or in industries and occupations in which health insurance coverage is less available or affordable. Compared to privately insured children, SCHIP-eligible children are three times more likely to be Hispanic and nearly two times more likely to be rated in fair or poor health. White children with Medicaid have more checkups than black children with Medicaid. Black children with Medicaid have more checkups than uninsured black children. White children with Medicaid or private insurance have more illness visits than uninsured white children. Black children with Medicaid or private insurance do not have more illness visits than uninsured black children. Over time, the same child receives more services when insured than when uninsured. Eligibility for Medicaid lowers the probability of no visits within a year by 10–13% (1/2 of baseline probability) and increases the probability of hospitalization by 14%. It also substantially increases the chances of being seen in a physician’s office relative to other sites. Between 1984 and 1992, increases in the proportion of children eligible for Medicaid reduced child mortality by an estimated 5%. Children of immigrants are less likely to take up Medicaid than are children of U.S.-born parents. Becoming eligible for Medicaid increased immigrant children’s use of physician visits more than it did for nonimmigrant children. Only children of U.S.-born parents had increased hospital use with greater Medicaid eligibility. Uninsured children, other things equal, were 8.8 percentage points (p <.01) more likely to rely on the ED or to have no usual source of care than those covered by Medicaid. They were also 2.8 percentage points (p <.01) more likely to have an unmet need for medical or surgical care and 7.4 percentage points (p <.01) more likely to have an unmet need for dental care. The families of uninsured children were 9.2 percentage points (p <.01) more likely to not feel confident that they could get the care they needed and 4.4 percentage points (p <.01) more likely to not feel satisfied with care than those in private and public insurance programs. Uninsured children were less likely than Medicaid-covered children to have at least one physician visit (regression adj. difference = 25.6; p <.01), one visit for well-child care (regression adj. difference = 25.6; p <.01), and at least one visit to a dentist of dental hygienist (regression adj. difference = 29.4; p <.01).

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Health Insurance is a Family Matter   Sample Size/ Data Source Outcome Measures Guendelman et al. (2001) Unfriendly Shores: How Immigrant Children Fare in the U.S. Health System. Health Affairs Data from 1997 NHIS (n = 14,290) Access and use of care Hernandez and Charney (1998) Health Status and Adjustment. In From Generation to Generation: The Health and Well-Being of Children in Immigrant Families 1994 NHIS; 1996 NHANES III General health status; chronic and acute health conditions Holl et al. (1995) Profile of Uninsured Children in the United States. Arch Pediatr Adolesc Med 1988 Child Health Supplement of the NHIS (n = 17,110) Utilization of medical services and health status; also an assessment of factors associated with lack of health insurance among children Kogan et al. (1995) The Effect of Gaps in Health Insurance on Continuity of a Regular Source of Care Among Preschool-Aged Children in the United States. JAMA Sample—8,129 children whose mothers were interviewed in the 1991 Longitudinal Follow-up to the National Maternal and Infant Health Survey Gap in health insurance, length of the gap, and continuity of care Ku and Freilach (2001) Caring for Immigrants: Health Care Safety Nets in Los Angeles, New York, Miami, and Houston Case study site visits with clinic and hospital administrators, doctors and nurses, local Medicaid and health officials, community-based organizations, and immigration and health experts and advocates: Los Angeles, New York, Houston, and Miami. The response of local providers and agencies to changes in state and local policies and practices affecting the access to insurance and health care services for immigrants in these areas

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Health Insurance is a Family Matter Findings Of the children not born in the United States, 52% were uninsured and 66% had a usual source of care compared to 20 and 92%, respectively of those that were native born. Of foreign-born children, 51% had their usual source of care at a doctor’s office or HMO, compared to 68% of U.S.-born children. Of those who were in less than excellent health, 39% of foreign-born children had not seen a doctor in the past year compared to 17% of U.S.-born children. Health insurance and immigrant policies should act to increase health care access for this population. Children in immigrant families tend to be healthier than children in U.S.-born families. Immigrant children have fewer acute and chronic health problems than U.S.-born children, including acute infectious and parasitic diseases; ear infections; acute accidents; chronic respiratory conditions; and chronic hearing, speech, and deformity impairments. However, over time, immigrant children lose this health advantage concordant with the length of residence in the United States. Children in immigrant families also have a high risk of certain health problems. Mexican immigrant children are more likely to be reported by their parents as being in fair or poor health and having teeth in only fair to poor condition. The report theorizes that these paradoxical findings suggest that strong family bonds among immigrants may act to sustain cultural orientations leading to healthful behavior or that there are other unknown factors at work serving as protection. The subsequent deterioration in the health of children from immigrant families the longer they reside in the United States suggests that with assimilation into American culture the protective aspects of immigrant culture diminish, allowing the harmful effects of low socioeconomic status, high poverty, and racial or ethnic stratification to emerge. Residence in the South (OR = 2.3) and West (OR = 1.9) and being poor, <100% FPL (OR = 2.2), or nearly poor, 100–200% FPL (OR = 2.1), are independently associated with being uninsured. Being uninsured was independently associated with having different sources for routine and sick care (adj. OR = 1.7; 95% CI = 1.5–2.0). There was also an independent association between never having routine care (adj. OR = 1.8; 95% CI = 1.2–2.7) and being uninsured, as well as an association between not having had a physician visit in the last 12 months and being uninsured (adj. OR = 1.5; 95% CI = 1.3–1.8). About ¼ of children were without health insurance for at least one month during their first three years of life. More than half of these children had a gap of more than six months. Less than half had only one site for care during the first three years of life. Those with a gap longer than six months had an increased chance of having more than one site for care (OR = 1.52; 95% CI = 1.19–1.96). This chance increased when emergency treatment was discounted as a multiple site of care. All cities reported a sharp decline in enrollment, but these could not be documented because most systems did not indicate if enrollees were immigrants. Data from Los Angeles indicated that the number of non-citizen immigrants and their children on Medicaid fell more than 50% between 1996 and 1998, but some believe that it has begun to climb again. More than half of low-income immigrants are uninsured and are particularly reliant on safety-net providers. Immigrants also tend to use alternative sources of care and delay or go without care. In every city, language barriers were viewed as the most serious threat to medical care quality. The access problem seemed to be the most severe for undocumented aliens who held an additional fear of being reported to the Immigration and Naturalization Service.

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Health Insurance is a Family Matter   Sample Size/ Data Source Outcome Measures Ku and Matani (2001) Left Out: Immigrants’ Access to Health Care and Insurance. Health Affairs Data from the NSAF; n = 109,992 Access to care Lave et al. (1998a) Impact of a Children’s Health Insurance Program on Newly Enrolled Children. JAMA Data for 887 families of newly enrolled children in 29 counties of western Pennsylvania Access to care and use of care Lieu et al. (1993) Race, Ethnicity, and Access to Ambulatory Care Among US Adolescents. Am. J Pub Health Data on 7,465 10–17-year-olds included in the Child Health Supplement to the 1998 NHIS Health care access and use McCormick et al. (2001) Annual Report on Access to and Utilization of Health Care for Children and Youth in the United States—2000. Ambulatory Pediatrics Data on insurance coverage, utilization, and expenditures from MEPS. (1996, n = 6,735; 1997, n = 11,278; and 1998 n = 7,839); data on hospitalization from the Database for Pediatric Studies Use of health care services and health expenditures for children and youth in the United States Newacheck et al. (1998b) Health Insurance and Access to Primary Care for Children. N Engl J Med Sample of 49,367 children under 18 from the 1993–1994 NHIS Access to care, use of care, satisfaction with care, and unmet needs

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Health Insurance is a Family Matter Findings Recent policy changes have limited immigrants’ access to insurance and health care. Fewer non-citizen immigrants and their children have Medicaid or job-based insurance, and many more are uninsured than native citizens or children of citizens. Of the non-citizen adults with incomes under 200% FPL, 58% were uninsured, and of the non-citizen children with non-citizen parents, 54% were uninsured. Overall, 41% of non-citizen adults, 38% of non-citizen children, and 21% of citizen children with non-citizen parents had no doctor, nurse, or ED visits in a year, while 21% of native adults and 13% of children of citizens had no doctor, nurse, or ED visits in a year. Even though insured noncitizens had less access to care than citizens, they had better access than uninsured noncitizens. The disparity in access to care has two components. First, noncitizens and their children are much more likely to be uninsured, which reduces the ability to access care. Secondly, even insured noncitizens and their children have less access to medical care than insured native-born citizens. There are nonfinancial barriers that they face such as language difficulties and lack of translations. Access to services improved after enrollment in the program. At 12 months of enrollment, 99% of the children had a regular source of care (vs. 89% prior to SCHIP) and 85% had a regular dentist (vs. 60% prior to SCHIP). The number of children reporting unmet needs or delayed care in the past six months decreased from 57% to 16%. The proportion of children seeing a physician increased from 59% to 64%, and the proportion visiting an ED decreased from 22% to 17%. Higher proportions of blacks and Hispanics than whites are uninsured (16% blacks, 28% Hispanics, 11% whites). Blacks and Hispanics reported poorer health status, made fewer doctor visits in the past year, and were more likely to lack a usual source of care than whites. Health insurance was associated with a greater increase in access to and use of care for minority youth than for white youth. After adjustment for health insurance, family income, need and other factors, racial differences persisted. About 2/3 of Americans are covered by private insurance, 19% by public, and 15% uninsured. Children with any private insurance were found more likely to have office visits than those on public insurance only or those that were uninsured (76% for those with private insurance vs. 67% for those with public insurance only and 51% for the uninsured). Dental visits and prescriptions filled showed the same pattern. Of those with some private insurance, 51% had dental visits, while 29% of those with only public insurance and 21% of those who were uninsured had dental visits. Of those with some private insurance, 61% had their prescriptions filled, while 56% of those with only public insurance and 43% of those that were uninsured had theirs filled. Publicly insured children were more likely to be hospitalized than those who had some private insurance or were uninsured. Of publicly insured children, 5.4% had hospital stays and 15.5% visited the ED. Of those with any private insurance, 2.4% had hospital stays and 12.5% of them visited the ED. For those that were uninsured, 1.9% had hospital stays and 10.8% visited the ED. An estimated 13% of U.S. children did not have health insurance in 1993–1994. Uninsured children were less likely to have a usual source of care (adj. OR = 6.1; 95% CI = 5.2–7.2). The uninsured were also more likely to have no regular physician (adj. OR = 1.7; 95% CI = 1.4–1.9), to be without access to care after hours (adj. OR= 1.6; 95% CI = 1.3–2.0), and to have families that were dissatisfied with at least one aspect of care (adj. OR = 1.4; 95% CI = 1.1–1.9). Uninsured children were more likely to have gone without needed medical (adj. OR = 5.8; 95% CI = 4.6–7.5), dental (adj. OR = 4.3; 95% CI = 3.7–4.9), or other health care. The uninsured were also less likely to have contact with a physician during the previous year (adj. OR = 2.1; 95% CI = 1.9–2.3).

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Health Insurance is a Family Matter   Sample Size/ Data Source Outcome Measures Newacheck et al. (1996) Children’s Access to Primary Care: Differences by Race, Income, and Insurance Status. Pediatrics Data from 7,578 1–17-year-old children of families responding to the 1987 NMES Measures of access to and use of care Newacheck et al. (2000a) The Unmet Health Needs of America’s Children. Pediatrics NHIS data from 1993 to 1996, 97,206 children <18 years old Used measures of unmet need for medical care, dental care, prescription medications, and vision care Newacheck et al. (1999) Adolescent Health Insurance Coverage: Recent Changes and Access to Care. Pediatrics Data on 14,252 adolescents, ages 10–18, from the 1995 NHIS Assess health insurance status, trends in health care coverage, demographic and socioeconomic correlates of coverage, and role of insurance in influencing use of and access to care Newacheck et al. (1998a) An Epidemiologic Profile of Children with Special Health Care Needs. Pediatrics Data from 1994 NHIS Disability. Sample based on 30,032 completed interviews for children <18 years old Characteristics of special needs children such as health status, access to care, satisfaction, and demographics

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Health Insurance is a Family Matter Findings Results are presented in four subgroups compared to children generally: poor children, minority children, uninsured children, and white non-poor insured children (reference group). Poor, minority, and uninsured children fared consistently worse on all indicators than children in the reference group, and of the children in at least one risk group, 40% are in another risk group as well. Children in all of these risk groups were less likely to have a usual source of care (OR = 0.76; 95% CI = 0.57–1.02 for poor children; OR = 0.56; 95% CI = 0.43–0.73 for minorities; and OR = 0.47; 95% CI 0.35–0.64 for the uninsured). These groups were more likely not to see a specific physician (OR = 1.88; 95% CI = 1.46–2.41 for the poor; OR = 2.44; 95% CI = 1.86–3.19 for minorities; and OR = 1.30; 95% CI = 1.01–1.67 for the uninsured) and were more likely to go without after-hours emergency care (OR = 1.30; 95% CI = 0.99–1.70 for the poor; OR = 1.77; 95% CI = 1.38–2.27 for minorities; and OR = 1.35; 95% CI = 1.03–1.77 for the uninsured). These groups were also more likely to have to wait 60 minutes or more at their site of care (OR = 2.03; 95% CI = 1.52–2.72 for the poor; OR = 2.12; 95% CI = 1.52–2.94 for minorities; and OR = 1.52; 95% CI = 1.14–2.03 for the uninsured). These individuals were more likely to be inadequately vaccinated for measles (OR = 1.40, 95% CI = 1.11–1.79 for the poor; OR = 2.66; 95% CI = 2.18–3.25 for minorities; OR = 1.09; 95% CI = 0.86–1.39 for the uninsured) and more likely to not have seen a physician for selected symptoms (OR = 1.25; 95% CI = 0.90–1.73 for the poor; OR = 1.54; 95% CI = 1.21–1.95 for minorities; OR = 1.65; 95% CI = 1.26–2.16 for the uninsured). Of children overall, 7.3% experience at least one unmet need. After adjusting for confounders, children who were near poor or poor were both about three times more likely to have an unmet need as non-poor children (adj. OR = 2.89; 95% CI = 2.52–3.32 for near poor adj. OR = 3.0; 95% C I = 2.53–3.56 for poor). Uninsured children were three times as likely to have an unmet need as an insured child (adj. OR = 2.92; 95% CI = 2.58–3.32). The unmet need for dental care was the most prevalent form of unmet need; 5.3% of children reported an unmet need for dental care in the last year during 1993–1996. An unmet need for medical care in the past year during 1993–1996 was experienced by 1.6% of children. In 1995, 14% of adolescents were estimated to be uninsured. Risk of being uninsured was higher for older adolescents, minorities, those in low-income families, and those in single-parent households. The uninsured were less likely to have a usual source of care (71% vs. 95.6%), more likely to have unmet needs (23.1% vs. 6.2%), and less likely to see a physician during the course of a year (74.9% vs. 89.8%). Between 1984 and 1995 the percentage of adolescents with some sort of insurance remained unchanged; however those with private insurance decreased and those with public insurance increased. Among U.S. children under 18 years, 18% were classified as a special needs. Of these children, 11% were uninsured, 6% were without a usual source of care, 18% were reported as dissatisfied with one or more aspect of care received at their usual source, and 13% had one or more unmet needs in the past year. Children with existing special needs are disproportionately poor and socially disadvantaged, and many of these children face significant barriers to health care.

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Health Insurance is a Family Matter   Sample Size/ Data Source Outcome Measures Currie and Gruber (2001) Public Health Insurance and Medical Treatment: The Equalizing Impact of the Medicaid Expansions. J Pub Econ U.S. birth certificate data 1987–1992 Use of four obstetrical procedures: cesarean delivery, fetal monitor, induced labor, and ultrasound Currie and Grogger (2002) Medicaid Expansions and Welfare Contractions: Off-setting Effects on Prenatal Care and Infant Health. J Health Econ U.S. birth certificate data 1990–1996 Use and timeliness of prenatal care; low and very low birthweight Dubay et al. (2001) Changes in Prenatal Care Timing and Low Birth Weight by Race and Socioeconomic Status: Implications for the Medicaid Expansion for Pregnant Women. Health Serv Res Data on 8.1 million births from the National Natality Files, 1980, 1986, and 1993. Births in all areas of the United States except CA, TX, WA, and upstate NY The rate of late initiation of prenatal care and the rate of low birthweight Durbin et al. (1997) The Effect of Insurance Status on Likelihood of Neonatal Interhospital Transfer. Pediatrics Southeastern Pennsylvania, five-county general acute care nonpediatric hospitals, 56,789 infants (0–28 days of age) admitted or born in a study hospital between Jan. and Dec. 1991 Transfer to another general or specialty acute hospital Ellwood and Kenney (1995) Medicaid and Pregnant Women: Who Is Being Enrolled and When. Health Care Financ Rev Medicaid enrollment and claims files for CA, GA, MI, and TN Women covered by Medicaid and/or deliveries covered by Medicaid

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Health Insurance is a Family Matter Findings Among younger and less educated women, Medicaid eligibility expansions were associated with increased use of each of the procedures. Among college-educated women for whom higher Medicaid eligibility may have resulted in higher rates of Medicaid coverage relative to private health insurance, higher Medicaid eligibility levels were associated with decreased use of these procedures. Increases in Medicaid eligibility had statistically significant effects on use of prenatal care: reducing the probability of inadequate care for both white and black women; increasing the proportion of each group getting care in the first trimester; and reducing late initiation of care by both groups of women. Increases in Medicaid eligibility slightly reduced the probability of very low birthweight babies to white mothers. No comparable effect was found for black women. From 1986 to 1993, rates of late initiation of prenatal care decreased by 6.0 to 7.8 percentage points beyond the estimated changes for the 1980–1986 period for white and African-American women of low socioeconomic status. The rate of low birthweight was reduced by 0.26 to 0.37 percentage point between 1986 and 1993 for white women of low socioeconomic status. Other white women and all African-American women of low socioeconomic status showed no relative improvement in the rate of low birthweight during 1986–1993. For white women with less than 12 years of schooling, improvements were found in the rate of low birthweight; the same was not found in other groups. Uninsured infants were almost twice as likely to be transferred as privately insured infants even with adjustments for prematurity, severity of illness, and level of the neonatal intensive care unit in the referring hospital (adj. RR = 1.96; 95% CI = 1.67–2.31). Infants with Medicaid were more likely to be transferred than similar privately insured neonates (adj. RR = 1.20; 95% CI = 1.01–1.43). Uninsured and publicly insured infants were more likely to be born prematurely (adj. RR = 1.49; 95% CI = 1.39–1.60) and to have both moderate (adj. RR = 1.11; 95% CI = 1.04–1.23) and high (adj. RR = 1.21; 95% CI= 1.11–1.32) illness severity compared to privately insured infants. Neonates with no insurance or those on Medicaid were more likely to be transferred than those with private insurance. Medicaid eligibility expansions and improved enrollment procedures for pregnant women during the late 1980s were examined, and it was found that more women enrolled in Medicaid and they enrolled earlier in pregnancy. The percentage of deliveries covered by Medicaid grew from 48 to 116% (depending on the state). However, there are still substantial numbers of women who are enrolling too late, and therefore the expansion may not promote significantly earlier use of prenatal care (39 to 54% joined Medicaid after the first trimester of pregnancy).

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Health Insurance is a Family Matter   Sample Size/ Data Source Outcome Measures Foster et al. (1992) The Impact of Prenatal Care on Fetal and Neonatal Death Rates for Uninsured Patients: A “Natural Experiment” in West Virginia. Obstet Gynecol 4,534 patients delivered in one Level 2 hospital between Jan. 1984 and Dec. 1986 in three counties of West Virginia Fetal death ratio Glied and Gnanasekaran (1996) Hospital Financing and Neonatal Intensive Care. Health Serv Res 1991 data from Greater New York Hospital Association and New York State Department of Health (45 hospitals, n = 139,076 births) Number of neonatal intensive care beds in a hospital Haas et al. (1993b) The Effect of Providing Health Coverage to Poor Uninsured Pregnant Women in Massachusetts. JAMA Massachusetts in-hospital, single-gestation live births in 1984 (n = 57,257) and 1987 (n = 64,346) Satisfaction rates, care initiated before the third trimester, and adverse infant outcomes Haas et al. (1993) The Effect of Health Coverage for Uninsured Pregnant Women on Maternal Health and the Use of Cesarean Section. JAMA All in-hospital, single-gestation births in 1984 (n = 57,257) and 1987 (n = 64,346) Rates of adverse maternal outcome and cesarean section for uninsured women and for two concurrent control groups: women with Medicaid and women with private insurance Homan and Korenbrot (1998) Explaining Variation in Birth Outcomes of Medicaid-Eligible Women with Variation in the Adequacy of Prenatal Support Services. Medi Care Medical record data on maternal risks and use of prenatal visits for more than 3,485 women receiving care at 27 ambulatory sites in four regions of California Birth outcomes

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Health Insurance is a Family Matter Findings A program was developed to give prenatal care to a population of uninsured patients. The overall fetal death ratio declined from 11.8 to 7.2 per 1,000 live births (p = .02) during the years of clinic operation. Uninsured patients experienced a reduction in fetal deaths during the program, from 35.4 to 7.0 per 1,000 live births (p = .02), whereas those covered by medical assistance did not experience a reduction. Privately insured patients also had a significant decrease, from 10.0 to 3.1 per 1,000 live births (p < .001). After suspension of the program the death ratio returned to 10.3 deaths per 1,000 live births in 1987. Over the same time period and for the same population, overall neonatal deaths declined. After adjusting for low birthweight and other measures of patient need and for hospital affiliation, the study found that hospitals with more privately insured patients—especially those with more privately insured, low-birthweight newborns—have statistically significantly more neonatal intensive care beds than those with fewer such patients. These findings remain within hospital affiliation categories as well. Between 1984 and 1987, the satisfaction rate for prenatal care declined from 96.4% to 93.8% for all women in the state. There was no statewide change in overall incidence of adverse birth outcomes. In 1984, uninsured women were less likely to receive satisfactory prenatal care and to initiate care before the third trimester. They were also more likely to suffer an adverse outcome. There was no statistically significant change between 1984 and 1987. In 1984, uninsured women had higher rates of adverse maternal health outcome than privately insured women (5.5% and 5.1%, respectively) and received fewer cesarean sections (17.2% and 23.0%, respectively). Between 1984 and 1987, there was no statistically significant change in the interpayer difference in adverse outcome relative to women with private insurance. Theinterpayer difference in cesarean sections between the uninsured and the privately insured was reduced by 2.3% (95% CI = 0.4%–4.2%), although the uninsured continued to undergo fewer cesarean section (22.4% vs. 25.9%); similar results were observed when the uninsured women were compared to women with Medicaid. The provision of health insurance alone to low-income pregnant women may not be associated with . improvement in maternal health An expansion of coverage was associated with an increase in the rate of cesarean sections. Providing at least one nutrition, psychosocial, and health education service session each trimester of care contributes significantly to explaining better birth outcomes when compared with providing fewer sessions. However, even with these services, outcomes differ among sites and types of settings. Although repeated support service sessions during prenatal care improve the chances of avoiding poor birth outcomes in low-income women, variations in outcomes at different sites and practice settings remain to be explained by other factors.

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Health Insurance is a Family Matter   Sample Size/ Data Source Outcome Measures Howell (2001) The Impact of Medicaid Expansions for Pregnant Women: A Synthesis of the Evidence. Med Care Res Rev Review of published literature and data from the NCHS for 1985–1991 (n = 3.8 million births in 1985 and 4.1 million in 1991) Prenatal care and birth outcomes Keeler and Brodie (1993) Economic Incentives in the Choice Between Vaginal Delivery and Cesarean Section. Milbank Q Literature review (225 journal articles, 3 dissertations, and 9 books between 1970 and 1992) Obstetric decisions Kenney and Dubay (1995) A National Study of the Impacts of Medicaid Expansions for Pregnant Women County-level aggregate birth certificates for all states (1986–1990) Prenatal care use Long and Marquis (1998) Effects of Florida’s Medicaid Eligibility Expansion for Pregnant Women. Am J Pub Health Birth and death certificates, linked to hospital discharge abstracts, Medicaid enrollment and claims files, and county health department records from July 1988 to June 1989 (to 100% of poverty), (n = 56,101) and in calendar year 1991 (to 150% of poverty), (n = 78,421) Use (amount and timing) of prenatal care, low-birthweight rates, and infant death rates Oberg et al. (1991) Prenatal Care Use and Health Insurance Status. J Health Care Poor Underserved 149 women at six hospitals in Minneapolis, MN Source, use, and quality of prenatal care

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Health Insurance is a Family Matter Findings 14 studies were used to look at the impact of Medicaid expansion. There was evidence that new groups of pregnant women were receiving coverage and that some women received improved prenatal care services. The improvements in prenatal care vary among states, and patterns were found in national studies showing a greater impact in the South and Midwest. The evidence stating that the expansion led to an improvement in birth outcomes is much weaker. When looking at the data from the NCHS, the results were similar to previous studies. However, an alternative explanation was offered for the decrease that did occur in infant mortality after the expansion. About half of the decline in infant mortality for unmarried women (those with the highest rates of very low birthweight) is due to declines in very low birthweight infant mortality from 1985 to 1991. Medicaid expansion did not result in a reduction in the rate of low birthweight; however, other factors were affected. Due to the expansion and additional resources, hospitals may have been able to expand or improve their neonatal ICUs, providing better care for these infants. There has been a dramatic increase in cesarean section rates; the cost is high, and there is wide variation in its use. The economic incentives for physicians, hospitals, payers, and mothers all come into play. Providers who encounter higher opportunity costs while attending to mothers in prolonged labor can reduce these costs by operating or restricting their practices. When physician and hospital charges for C-sections ($7,186) and for vaginal births ($4,334) were compared, the C-section cost was 66% more. Private insurance pays more, and there are higher rates of C-sections in populations with private coverage. Not only are physicians, hospitals, and payers influenced by financial incentives, so are the mothers. The mainly indirect evidence on financial incentives shows that insured mothers have low marginal cost sharing when they undergo C-sections. Mothers who have private FFS insurance have higher rates of C-sections than mothers who are covered by staff-model HMOs, are uninsured, or are on public insurance. Medicaid expansions were associated with a reduced percentage (from 20.8% to 19.2%) of white women receiving late or no prenatal care in the South and Midwest. The number of deliveries covered by Medicaid increased by 47% after expansion. Access to prenatal care for the target population (low-income women without private insurance) improved: prior to the expansion, 2.3% had no prenatal care, and after the expansion, 1.6% had no prenatal care. Among those receiving care, fewer delayed care after the expansion (4.8% vs. 6.8%), and they had more prenatal visits (11.1 vs. 10.5). The rate of low birthweights declined after the expansion (61.8 vs. 67.9 per 1,000). The number of infant deaths also declined from 7.3 per 1,000 to 5.9 per 1,000. In this study, insurance status was significantly related to the source of prenatal care (p <.0001). Private physicians cared for 52% of privately insured, 23% of those insured by Medicaid, and 2% of uninsured women. Medicaid and uninsured women, when compared to privately insured women, used public clinics as their primary source of care, experienced longer waiting times, and were more likely to lack continuity of care with a provider.

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Health Insurance is a Family Matter   Sample Size/ Data Source Outcome Measures Phibbs et al. (1993) Choice of Hospital for Delivery: A Comparison of High-Risk and Low-Risk Women. Health Serv Res Data from 1985 California Office of Statewide Health Planning and Development discharge abstracts and hospital financial data Delivery where there was a newborn intensive care unit Piper et al. (1990) Effects of Medicaid Eligibility Expansion on Prenatal Care and Pregnancy Outcome in Tennessee. JAMA Linked birth, death certificate, and Medicaid enrollment files Pregnant women eligible for Medicaid or deliveries covered by Medicaid Ray et al. (1997) Effect of Medicaid Expansion on Pre-term Births. Am J Prev Med 610,056 singleton births to African-American or Caucasian women Pregnant women eligible for Medicaid or deliveries covered by Medicaid and prenatal care use Salganicoff and Wyn (1999) Access to Care for Low-Income Women: The Impact of Medicaid. J Health Care Poor Underserved Telephone interview survey of a representative cross-sectional sample of 5,200 low-income women in MN, OR, TN, FL, and TX Health insurance coverage, health status, access to care, use of care, and satisfaction Singh et al. (1994) Impact of the Medicaid Eligibility Expansions on Coverage of Deliveries. Fam Plan Perspect Alan Gutmacher Institute Survey of States (national study comparison of states [50 states and District of Columbia, 5 states did not respond ]), 1991 Women covered by Medicaid and/or deliveries covered by Medicaid Stafford (1990) Cesarean Section Use and Sources of Payment: An Analysis of California Hospital Discharge Abstracts. Am J Pub Health California data on hospital deliveries (461,066 deliveries) in 1986 Cesarean section Stafford et al. (1993) Trends in Cesarean Section Use in California, 1983–1990. Am J Obstet Gynecol Data from CA discharge abstracts on hospital deliveries in 1983–1990 (379,759–587,508 annual deliveries) Cesarean section

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Health Insurance is a Family Matter Findings Results show that high-risk and low-risk women do not have the same choice process. Hospital quality was more important for high-risk women. Results also show that factors influencing choice of hospital are different for those who are privately insured and those who are on Medicaid. High-risk women who were covered by Medicaid were less likely to deliver in a hospital with a newborn intensive care unit than high-risk women who were privately insured. An expansion to all married women meeting income requirements increased the percentage of births covered by Medicaid from 22 to 29%. The year before Medicaid was compared to the year after; there were no improvements in the use of prenatal care in the first trimester, no changes in the rates of very low and moderately low birthweight and neonatal mortality. There were no improvements in these outcomes for the groups where coverage change was the greatest. The percentage of deliveries covered by Medicaid increased from 21 to 51%; however Medicaid coverage increased only from 10 to 37% in the first trimester. The rate of inadequate prenatal care went down for all low-income groups and low-education groups (18.5% to 13.7% for unmarried women). Medicaid expansion increased enrollment and use of prenatal care in high-risk women; however it did not decrease the likelihood of preterm birth. Low-income women were found to experience considerable barriers to care. Uninsured low-income women have significantly more trouble obtaining care, receive fewer recommended services, and are more dissatisfied with the care they receive than their insured counterparts. Women on Medicaid had access to care that was comparable to their low-income privately insured counterparts but, in general, had significantly lower satisfaction with their providers and their plans. The number of deliveries covered by Medicaid rose from 0.5 million (14.5% of deliveries) in 1985 to 1.2 million (32.0% of deliveries) in 1991. The rise in Medicaid-covered births was due in part to greater coverage among women who previously had received uncompensated care, but about half of the increase was from new coverage of women who in the mid-1980s were covered by private insurance. Cesarean sections were performed for 24.4% of deliveries; women with private insurance had the highest rates of cesarean section (29.1%). Lower rates were seen for women covered by non-Kaiser HMOs (26.8%), Medi-Cal (22.9%), Kaiser (19.7%), self-pay (19.3%), and indigent services (15.6%). Vaginal birth after cesarean occurred more often in women covered by Kaiser (19.9%) and indigent services (24.8%) compared to those with private coverage (8.1%). There was a sizable, although less pronounced, association between payment source and cesarean sections for breech presentation, dystocia, and fetal distress. Accounting for maternal age and race or ethnicity did not alter the findings. California C-section rates increased from 21.8% in 1983 to 25% in 1987 and then decreased to 22.7% in 1990. Patterns were similar for all ages, races, and/or ethnicities. Differences in C-section use among patients with different insurance status increased from 1983 to 1990. Privately insured women consistently had higher rates of C-sections.

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Health Insurance is a Family Matter   Sample Size/ Data Source Outcome Measures Weis (1992) Uninsured Maternity Clients: A Concern for Quality. Appl Nursing Res Chart review of inpatient maternity client medical records; 500 cases: half uninsured and half insured (public and private) Length of stay, maternal complications

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Health Insurance is a Family Matter Findings Compared with the privately insured, the uninsured had more life-style risks. Uninsured women had a shorter hospital stay with more maternal complications. Insurance coverage and prenatal care were positive predictors of birthweight, while life-style risk factors detracted. Length of stay was not influenced by insurance coverage but rather by health problems before delivery.

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