THE EFFECTS OF WELFARE REFORM ON LOW INCOME WOMENS INSURANCE STATUS AND PRENATAL CARE USE

1
THE EFFECTS OF WELFARE REFORM ON LOW INCOME
WOMENS INSURANCE STATUS AND PRENATAL CARE USE

• REGION V AND VII MCH CONFERENCE
• CHICAGO, ILLINOIS
• APRIL 22, 2002

2
Arden Handler, DrPHDeborah Rosenberg,
PhDKathleen Adams, PhDMeagan Zimbeck, MPH
3
Welfare Reform

• Personal Responsibility and Work Opportunity
  Reconcilation Act of 1996 (PRWORA)
• replaced AFDC entitlement with TANF block grant
• imposed new work requirements and time limits
• decoupled welfare eligibility from Medicaid
  eligibility

4
Welfare Reform and Medicaid

• Families who are no longer eligible for TANF may
  still qualify for Medicaid if their incomes meet
  the eligibility standards for AFDC that were in
  place on July 16, 1996
• Women leaving welfare for work can still use 12
  months of Transitional Medicaid Assistance (TMA)

5
Welfare Reform and Medicaid

• 5 year ban for new (after August 1996) legal
  immigrants on receiving Medicaid and most other
  public benefits although some states have
  maintained or restored coverage with state funds
• PRWORA did offer states new options to expand
  Medicaid coverage for poor and near poor parents
• allowed states to use less restrictive methods
  when counting income and resources to determine
  eligibility

6
Welfare Reform and Medicaid

• Decoupling of Medicaid eligibility from TANF
  eligibility had potential to ensure coverage for
  many low-income families as families leaving
  welfare might still be eligible for Medicaid
• Evidence to date suggests that this has not been
  the case

7
Welfare Reform and Medicaid

• In 1998, Medicaid covered 6 million women 15-44
  --1.5 million fewer than 1994 (Gold, 1999)
• For low-income mothers, enrollment in Medicaid
  dropped from 50 in 1994 to 39 in 2000 (Wyn et
  al. 2001 Mann et al., 2002)

8
Welfare Reform and Medicaid

• Decline in Medicaid coverage only partly
  compensated for by increase in private insurance
  coverage
• 37 of women with incomes lt100 FPL and 27 of
  women with incomes between 100-199 FPL were
  uninsured in 2000 (Mann et al. 2002)
• Recent data shows some turn-around as the result
  of state expansion efforts, some associated with
  CHIP

9
Welfare Reform and Medicaid

• Reasons for decline in Medicaid coverage
• delinking rules implemented incorrectly --e.g.,
  joint application still used so women applying
  for Medicaid subject to TANF related diversions
  and sanctions
• many families eliminated from cash did not know
  they were eligible for Medicaid
• women not aware of eligibility for TMA
• little education of women about eligibility

10
Welfare Reform, Pregnancy and Medicaid

• As a result of Medicaid expansions of the late
  1980s and 1990s many states cover pregnant
  women beyond the required 133 FPL including 12
  at or above 200 FPL
• There should be virtually no effect of welfare
  reform on Medicaid coverage during pregnancy
  although effect on coverage prior to pregnancy
  expected

11
Welfare Reform, Pregnancy and Medicaid

• Proportion of births paid for by Medicaid
  increased from 17 in 1985 to 35 in 1998 (AGI,
  1987 NGA, 2001)
• However, the percentage of pregnant women covered
  by Medicaid declined from almost 24 in 1993 to
  only 15 by 1997 (Thorpe, 1999)

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Welfare Reform, Pregnancy and Medicaid

• Table 1 Distribution of Health Insurance
  Coverage Among Pregnant Women, 1990-1997
• Source of Coverage
• Year Private Insurance Medicaid Other Uninsured T
  otal
• (millions of women)
• 1997 69.0 15.2 2.1 13.7 3.4
• 1996 66.1 18.3 1.9 13.7 3.4
• 1995 63.2 20.8 2.4 13.6 3.4
• 1994 63.1 20.0 4.2 12.7 3.4
• 1993 62.3 23.6 2.9 11.2 3.6
• 1992 61.4 23.0 3.7 11.9 3.6
• 1991 61.6 22.2 4.2 12.0 3.5
• 1990 63.7 21.6 3.7 11.0 3.6
• Source Thorpe, Kenneth. The Distribution of
  Health Insurance Coverage Among Pregnant Women,
  1990-1997. Washington, DC March of Dimes, 1999.
  45

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Welfare Reform, Pregnancy and Medicaid

• Over 28 of pregnant women in poverty in 1997
  were uninsured versus only 3 of women earning at
  least 3x the poverty level (Thorpe, 1999)
• However, over 77 of uninsured pregnant women
  were eligible for Medicaid in 1997 (Thorpe, 1999)

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Welfare Reform, Pregnancy and Medicaid

• Only a few analyses have examined the effect of
  welfare policy change on prenatal care
  utilization and pregnancy outcomes
• Findings have been equivocal
• All analyses use data from years prior to when a
  significant effect of PRWORA might be expected

15
Welfare Reform, Insurance Status and Prenatal
Care Use

• Study Objective
• To use PRAMS data from 9 states for the years
  1994-2000 to examine the effect of welfare reform
  on insurance coverage, PNC utilization, WIC
  coverage, and barriers to prenatal care among
  women on public aid and their very low income
  counterparts

16
Welfare Reform, Insurance Status and Prenatal
Care Use

• PRAMS is a population and state based
  surveillance system - documents the behaviors and
  experiences of women during the preconceptional,
  prenatal, delivery and postpartum periods
• PRAMS data includes a follow-back questionnaire
  and a linked birth certificate for each
  maternal-infant pair

17
Welfare Reform, Insurance Status and Prenatal
Care Use- PRAMS States Included in the Analysis

• Alaska
• Florida
• Georgia
• Maine
• New York (excludes NYC)

• Oklahoma
• S. Carolina
• Washington
• West Virginia

18
Welfare Reform, Insurance Status and Prenatal
Care Use

• Population studied Public AID women
• Women who reported on the PRAMS questionnaire
  that Aid was their only source of income
  includes aid such as TANF (formerly AFDC),
  welfare, public assistance, general assistance,
  food stamps, or SSI, who were unmarried, not
  primparous and who responded that their income
  was in the lowest PRAMS income category (or two
  lowest in Alaska or less than 7800 in OK) --
  all nine states

19
Welfare Reform, Insurance Status and Prenatal
Care Use

• Population studied Non-public aid Low Income
  Women
• Women who responded that their income was in the
  lowest PRAMS income category (or two lowest in
  Alaska or less than 7800 in OK) and not
  reporting Aid as an income source
• unmarried and not primiparous
• five states AK, NY, OK, SC, ME
• Crude but conservative categorization - does not
  take into acct. number of dependents--cannot
  perfectly match welfare eligibility levels

20
Welfare Reform, Insurance Status and Prenatal
Care Use

• Independent Variable Time (1994/ 1996 versus
  1999)
• Dependent Variables
• Insurance Prior to Pregnancy (1996-1999)
• Insurance During Pregnancy (1994-1999)
• Insurance at Delivery (1994-1999)
• First Trimester Prenatal Care Initiation
  (1994-1999)
• Kotelchuck Adequacy of Prenatal Care Index
  (1994-1999)

21
Welfare Reform, Insurance Status and Prenatal
Care Use

• Analysis
• Descriptive presentation of data
• Data weighted to account for sampling design
• Future analysis
• Chi-square tests to examine differences in
  proportions before and after
• Trend analysis
• Multivariable analysis
• to adjust for changes in demographic profile of
  women over time
• to adjust for changes in economic and social
  environment over time

22
Welfare Reform, Insurance Status and Prenatal
Care Use

• Number of Women Reporting that Public Aid was
  their only Source of Income in 9 PRAMS states
• 1994 - 659
• 1995 - 559
• 1996 - 491
• 1997 - 360
• 1998 - 255
• 1999 - 156

• Number of Non-Public Aid Low Income Women in 5
  PRAMS States
• 1994 - 115
• 1995 - 82
• 1996 - 124
• 1997 - 125
• 1998 - 152
• 1999 - 144

23
Welfare Reform, Insurance Status and Prenatal
Care Use

• Insurance Prior to Pregnancy (1996-1999)- Public
  Aid Only Women (9 states)
• Medicaid (includes Medicaid only, and women who
  report Medicaid plus other insurance)
• From 77.5 in 1996 to 60.4 in 1999
• Private insurance
• From 5.1 in 1996 to 5.4 in 1999
• Uninsured
• From 17.5 in 1996 to 34.3 in 1999

24
Welfare Reform, Insurance Status and Prenatal
Care Use

• Medicaid Insurance Early-Prior to pregnancy
  (1996-1999) or at the time woman knew she was
  pregnant (1994-5) - Public Aid Only Women (9
  states)
• (Medicaid coverage includes Medicaid only)
• From 72.7 in 1994 to 41.7 in 1999

25
Welfare Reform, Insurance Status and Prenatal
Care Use

• Insurance During Pregnancy (1994-1999)- Public
  Aid Only Women (9 states)
• Medicaid (includes Medicaid only, and women who
  report Medicaid plus other insurance)
• From 94.2 in 1994 to 83.7 in 1999
• Private insurance
• From 3.1 in 1994 to 9.2 in 1999
• Uninsured
• From 2.7 in 1994 to 7.0 in 1999

26
Welfare Reform, Insurance Status and Prenatal
Care Use

• Insurance at Delivery (1994-1999) -Public Aid
  Only Women (9 states)
• Medicaid (includes Medicaid only, and women who
  report Medicaid plus other insurance)
• From 92.2 in 1994 to 82.8 in 1999
• Private insurance
• From 3.7 in 1994 to 8.7 in 1999
• Uninsured
• From 4.2 in 1994 to 8.5 in 1999

27
Welfare Reform, Insurance Status and Prenatal
Care Use

• Medicaid Insurance Before or at Time of Knowledge
  of Pregnancy, During Pregnancy and Delivery
  (1994-1999) -Public Aid Only Women (9 states)
• 1994- 68.4
• 1999- 51.1

28
Welfare Reform, Insurance Status and Prenatal
Care Use

• No Prenatal Care (1994 -1999)-Public Aid Only
  Women (9 states)
• 1994 - 1.2
• 1999 - 0.7

29
Welfare Reform, Insurance Status and Prenatal
Care Use

• First Trimester Prenatal Care Initiation (1994
  -1999)-Public Aid Only Women (9 states)
• 1994 - 64
• 1999 - 64

30
Welfare Reform, Insurance Status and Prenatal
Care Use

• Adequacy of care (1994-1999)- Public Aid Only
  Women (9 states)
• Inadequate Care
• 1994 - 28.8
• 1999 - 32.2
• Intensive Use
• 1994 - 26.2
• 1999 - 23.2

31
Welfare Reform, Insurance Status and Prenatal
Care Use

• Insurance Prior to Pregnancy (1996-1999)-Low
  Income Women (5 states)
• Medicaid (includes Medicaid only, and women who
  report Medicaid plus other insurance)
• From 41.8 in 1996 to 24.2 in 1999
• Private insurance
• From 9.1 in 1996 to 8.7 in 1999
• Uninsured
• From 49.2 in 1996 to 67.2 in 1999

32
Welfare Reform, Insurance Status and Prenatal
Care Use

• Medicaid Insurance Early-Prior to pregnancy
  (1996-1999) or at the time woman knew she was
  pregnant (1994-5) - Low Income Women (5 states)
• (Medicaid coverage includes Medicaid only)
• From 45.1 in 1994 to 13.5 in 1999

33
Welfare Reform, Insurance Status and Prenatal
Care Use

• Insurance During Pregnancy (1994-1999)- Low
  Income Women (5 states)
• Medicaid(includes Medicaid only, and women who
  report Medicaid plus other insurance)
• From 83.1 in 1994 to 84.1 in 1999
• Private insurance
• From 9.2 in 1994 to 7.8 in 1999
• Uninsured
• From 7.7 in 1994 to 8.1 in 1999

34
Welfare Reform, Insurance Status and Prenatal
Care Use

• Insurance at Delivery (1994-1999) -Low Income
  Women (5 states)
• Medicaid (includes Medicaid only, and women who
  report Medicaid plus other insurance)
• From 81.2 in 1994 to 84.8 in 1999
• Private insurance
• From 6.4 in 1994 to 7.3 in 1999
• Uninsured
• From 12.4 in 1994 to 7.9 in 1999

35
Welfare Reform, Insurance Status and Prenatal
Care Use

• Medicaid Insurance Before or at Time of Knowledge
  of Pregnancy, During Pregnancy and Delivery
  (1994-1999) -Low Income Women (5 states)
• 1994- 43.1
• 1999- 21.6

36
Welfare Reform, Insurance Status and Prenatal
Care Use

• No Prenatal Care (1994 -1999)-Low Income Women (5
  states)
• 1994 - 2.9
• 1999 - 2.4

37
Welfare Reform, Insurance Status and Prenatal
Care Use

• First Trimester Prenatal Care Initiation (1994
  -1999) -Low Income Women (5 states)
• 1994 - 55
• 1999 - 65

38
Welfare Reform, Insurance Status and Prenatal
Care Use

• Adequacy of Care- (1994-1999) Low Income Women (5
  states)
• Inadequate Care
• 1994 - 23.9
• 1999 - 17.2
• Intensive Use
• 1994 - 25.8
• 1999 - 31.2

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Welfare Reform, Insurance Status and Prenatal
Care Use

• Limitations
• Data are only from 9 states- States do not
  representative a particular geographic region of
  the US or US as a whole
• No statistical analysis at this time
• Changes may reflect changes in risk pool of the
  women over time
• Comparisons between 1994/1996 and 1999 without
  statistical testing ignore the fluctuations in
  the years between 1994 and 1999

40
Welfare Reform, Insurance Status and Prenatal
Care Use

• Limitations
• Public Aid Only women include some women who are
  not AFDC/TANF recipients but are recipients of
  other types of assistance such as SSI or food
  stamps only
• Low-income women who are public aid eligible
  cannot be precisely defined
• Small sample sizes in the public aid group in the
  later years and low income group in all years
• Ultimately, time series type analysis cannot
  directly establish causal link between welfare
  reform and outcomes

41
Welfare Reform, Insurance Status and Prenatal
Care Use

• Findings for women on public aid
• the number of women on public aid has declined
  between 1994-1999 in the 9 states
• Medicaid coverage before and during pregnancy,
  and at delivery has declined since 1994
• private insurance use increased during pregnancy
  and at delivery but is essentially the same prior
  to pregnancy
• however, uninsuredness before and during
  pregnancy and at delivery has also increased

42
Welfare Reform, Insurance Status and Prenatal
Care Use

• Findings for women on public aid
• the percentage of women with no pnc has declined
  slightly
• first trimester pnc use has remained the same
• inadequate care has increased
• intensive pnc use has decreased

43
Welfare Reform, Insurance Status and Prenatal
Care Use

• Findings for low income women
• Medicaid insurance prior to pregnancy has
  declined and uninsuredness prior to pregnancy has
  increased
• Medicaid coverage and uninsuredness during
  pregnancy has increased slightly private
  insurance coverage has decreased slightly

44
Welfare Reform, Insurance Status and Prenatal
Care Use

• Findings for low income women
• Medicaid and private insurance at delivery have
  increased slightly while uninsuredness has
  declined

45
Welfare Reform, Insurance Status and Prenatal
Care Use

• Findings for low income women
• the percentage of women with no pnc has declined
  slightly
• the percentage of women with first trimester pnc
  initiation has increased
• inadequate care has decreased
• intensive care use has increased

46
Conclusions

• Women in the 9 PRAMS states in this study who
  report public aid as their only source of income
  and who are unmarried, multiparous and are in the
  lowest income category on the PRAMS questionnaire
  should be eligible for Medicaid during pregnancy
  and delivery and most likely prior to pregnancy
• However, Medicaid coverage for prepregnancy,
  prenatal and delivery care has declined markedly
  between 1994 and 1999 for these women

47
Conclusions

• The decline in Medicaid coverage for public aid
  only women has only been partially compensated
  for by increases in private coverage in fact,
  there has been an increase in uninsuredness for
  this group during pregnancy and at delivery, at a
  time when all pregnant women in the US with
  incomes less than 133 of the FPL are eligible
  for Medicaid coverage during pregnancy

48
Conclusions

• Non public aid low-income women appear to be less
  affected by declines in Medicaid coverage during
  pregnancy and especially at delivery but do
  appear to be affected by declines in Medicaid
  coverage prior to pregnancy

49
Conclusions

• While there has been an increase in first
  trimester care use for the nation between
  1994-1999, there has been no progress for the
  women on public aid in these 9 states
• The findings in regard to inadequate care and
  intensive care for the public aid women in these
  9 states are in contrast to the pattern in the
  nation during this period
• The trends in pnc use for the low income women
  are consistent with national trends

50
Conclusions

• Statistical testing, trend analysis and
  multivariable analysis are necessary to fully
  interpret these trends
• Data are consistent with a negative effect of
  welfare reform on low income womens insurance
  status, particularly for women on public aid
• Data also suggest a negative effect of welfare
  reform on prenatal care utilization, particularly
  for women on public aid

51
Conclusions

• Positive effects of Medicaid coverage on
  perinatal outcomes will be diminished if
  low-income women lose access to health insurance
  prior to pregnancy as well as during pregnancy
• Data can be used to advocate for welfare policy
  that truly separates cash assistance from health
  insurance to ensure that the most vulnerable
  women do not lose their health benefits