Title: The Efficacy of Medicaid Family Planning Waivers On Young Women: Difference-in-Difference Evidence from National Microdata
1The Efficacy of Medicaid Family Planning Waivers
On Young Women Difference-in-Difference
Evidence from National Microdata
- Amy M. Wolaver
- Bucknell University
- Health Economics Interest Group Meeting, ARM
- June 7, 2008
2Alternative Views on Contraception
- When the history of civilization is written, it
will be a biological history and Margaret Sanger
will be its heroine." - H.G. Wells
- Chastity The most unnatural of the sexual
perversions. - Aldous Huxley
- For most women, including women who want to have
children, contraception is not an option it is a
basic health care necessity. - Louise Slaughter
- You must strive to multiply bread so that it
suffices for the tables of mankind, and not
rather favor an artificial control of birth,
which would be irrational, in order to diminish
the number of guests at the banquet of life. - POPE PAUL VI, speech, Oct. 4, 1965
- The best contraceptive is the word no - repeated
frequently. - Margaret Smith
- The best contraceptive is a glass of cold water
not before or after, but instead. - Author Unknown
3Introduction
- Half of pregnancies in US are unintended
(Guttmacher Institute) - Teen pregnancy has fallen in US but remains
higher than other countries - Problems with teen childbearing
- Public costs (Medicaid, welfare, education)
- Health of mother infant (low birthweight,
premature birth etc)
4Family Planning Coverage for Poor Women
- Medicaid accounts for over ½ of Federal funds for
contraceptive services - More than Title X funds
- Copays are prohibited
- Federal matching rate more generous than for
other Medicaid services
5Medicaid Section 1115 Family Planning Waivers
- Provides limited (contraceptive, STD testing,
counseling) benefits to additional persons not on
regular Medicaid - Must be budget neutral (to Medicaid) over 5 year
period - 90 federal matching rate for BC
- Higher than other services
- Justification reduces more costly, but
lower-matched Medicaid births - Additional public savings from related avoided
costs
6Political Considerations
- Most estimates find FP waivers cost-neutral or
saving from federal perspectives - Attractive to states because of generous match
rate - Public funding of contraception remains
controversial - Encourages teen sex?
- Unintended consequences?
- Religious objections to any contraception
7Waiver History
- Two strategies
- Extending FP services after regular (post-partum)
Medicaid loss 1994 Rhode Island SC
post-partum extension - Raise Income cut-off for FP services California
PACT 1997 - As of 2/1/08 Twenty-seven states have implemented
- Variation in timing, eligibility rules, coverage
of teens/males
8Previous Research on Public Contraceptive Coverage
- May increase provider availability (Frost et al.
2004) - Increases use, more effective BC methods (Forrest
Samara 1996) - Inattention to endogeneity may lead to
underestimates of policy efficacy (Mellor 1998) - Income-related waivers reduce state birth rates
(Lindrooth McCullough 2007)
9Methods
- Difference-in-difference-in-difference
- Create treatment group (eligible/would be
eligible) based on waiver rules in policy
matched states - Two control groups Medicaid eligible, ineligible
for both FP regular Medicaid
10Methods, continued
- Stage 1 Difference-in-difference (DD)
- Compare pre- post-waiver outcomes of treatment
control groups within waiver states (DD1) - Repeat with treatment control in
matched/comparison states (DD2) - Stage 2 Difference-in-difference-in-difference
(DDD) - Compare first stage results DD1-DD2
11Regression Framework
- Because data are panel
- same women in pre- post-, tx control groups
- policy variation also occurring as cohort ages,
experiences life cycle fertility changes
12Regression Framework, contd
- OLS Fixed effects
- Also includes time state dummies
- Individual fixed effects
- Includes controls for age, menses y/n, Medicaid
eligible, urban - Linear probability models
- Fixed effects complex in nonlinear models, can
introduce biases (Greene 2004) - Interaction effects even more complex in
nonlinear models (Ai Norton 2003) - But, heteroskedasticity, predictions outside 0/1
bounds - Use LPM, correct standard errors for
heteroskedasticity, check against WLS estimates
13Data
- 1997 National Longitudinal Survey of Youth
- Women aged 12-18 in 1997
- Annual waves available from 1997-2005
- Only women 14 or older
- Policy information from Guttmacher Institute,
cross checked with CMS
14Outcomes
- Childbearing
- Pregnant since last interview
- Gave birth since last interview
- Pregnant w/out live birth (abortion, miscarriages
still births combined) since last interview - Contraceptive use
- At last intercourse
- Typical pregnancy risk w/ usual BC method
- Percent of time use BC
- Sexually active since last interview
15Policy Variation
Variable Fraction of Sample
In a Waiver state (pre or post waiver) 55.9 (49.7)
In a state with income eligibility waiver (pre or post waiver) 36.4 (48.1)
In any Medicaid loss extension waiver state (pre or post waiver) 4.48 (20.7)
In a post-natal extension state (pre or post waiver) 20.5 (40.3)
Simulated Income Eligibility, in waiver state 24.0 (42.7)
Simulated Income Eligibility, in comparison states 6.62 (24.8)
Simulated Extension Eligibility, in waiver states 12.12 (24.9)
Simulated Extension Eligibility, in comparison states 22.6 (41.8)
Fraction of Sample Post-waiver years, all states 77.4 (41.8)
N 23,583
16Waiver/Comparison States Characteristics
Variable Waiver States Comparison States
Fathers High Grade Completed 12.5 (3.18) 12.8 (3.06)
Ratio Gross Income to Federal Poverty Level 294.6 (3.00) 305.0 (3.22)
Black 31.6 (46.49) 21.7 (41.25)
Hispanic 23.3 (42.47) 16.2 (36.82)
Year of First Sex 1999 (3.08) 1999 (3.15)
Ever had Sex 74.1 (43.73) 74.1 (44.74)
Sex since last survey 49.25 (50.00) 48.81 (49.99)
Used BC, last sex 73.1 (44.37) 73.2 (44.28)
Pregnant, last year 15.7 (36.38) 15.9 (36.57)
Pregnancy, no live birth 9.8 (29.74) 9.8 (29.70)
Pregnancy risk, usual BC 13.79 (25.3) 13.78 (28.7)
Pregnancy risk, usual BC, sexually active 21.6 (36.2) 21.5 (40.9)
Age 19.3 (3.12) 19.2 (3.15)
Urban 84.2 (43.50) 80.2 (47.92)
Medicaid Eligible 23.3 (42.25) 21.1 (40.78)
N 13,180 10,413
17DDD Results
OLS OLS OLS OLS Fixed Effects Fixed Effects Fixed Effects Fixed Effects Fixed Effects Fixed Effects Fixed Effects Fixed Effects
Outcome DDD Std Err Std Err R2 DDD DDD Std Err Std Err R2 N persons persons
Any Type of Family Planning Waiver Any Type of Family Planning Waiver Any Type of Family Planning Waiver Any Type of Family Planning Waiver Any Type of Family Planning Waiver Any Type of Family Planning Waiver Any Type of Family Planning Waiver Any Type of Family Planning Waiver Any Type of Family Planning Waiver Any Type of Family Planning Waiver Any Type of Family Planning Waiver Any Type of Family Planning Waiver Any Type of Family Planning Waiver
Pregnant in past yeara -0.148 0.022 0.26 0.26 -0.132 0.024 0.19 23437 23437 4314
Gave Birth in past yeara -0.0505 0.013 0.12 0.12 -0.0462 0.016 0.08 23437 23437 4314
Pregnancy non-live birtha -0.097 0.17 0.16 0.16 -0.086 0.019 0.16 23437 23437 4314
Sexually Active in past yeara -0.068 0.033 0.30 0.30 -0.050 0.029 0.30 18955 18955 4274
Pregnancy Risk, usual BC method 0.724 1.87 0.069 0.069 0.0036 0.0024 0.07 17785 17785 4141
Used BC last sexa 0.020 0.063 0.034 0.034 -0.017 0.084 .025 6073 6073 2903
Percent sexual intercourse used BC 5.13 4.11 0.083 0.083 9.88 4.31 0.06 11479 11479 3377
- Source Authors calculations from 1997 NLSY.
Regressions also control for state, sample year,
age, menses, Medicaid eligibility, and
urbanicity. Standard errors corrected for
clustering at individual level. ,
Statistically significant at the 1, 5 level. a.
Standard errors corrected for heteroskedasticity
in linear probability models.
18DDD Results, contd
- Source Authors calculations from 1997 NLSY.
Regressions also control for state, sample year,
age, menses, Medicaid eligibility, and
urbanicity. Standard errors corrected for
clustering at individual level. ,
Statistically significant at the 1, 5 level. a.
Standard errors corrected for heteroskedasticity
in linear probability models.
19DDD Results, contd
- Source Authors calculations from 1997 NLSY.
Regressions also control for state, sample year,
age, menses, Medicaid eligibility, and
urbanicity. Standard errors corrected for
clustering at individual level. ,
Statistically significant at the 1, 5 level. a.
Standard errors corrected for heteroskedasticity
in linear probability models.
20General Results
- Decreases sexual activity
- Decreases probability of pregnancy, giving birth,
combined abortion, miscarriages stillbirth - Large, statistically significant effects
- Greater relative impact on combined abortion,
miscarriages stillbirth than on giving birth - Extension waivers have larger impact
- No measured impact on contraceptive outcomes
21Robustness Checks
- Dropping pre-1997 waiver states
- Income eligibility waivers have negative,
statistically significant impact on pregnancy
giving birth - Extension waivers impact same magnitude except in
FE (drops to match OLS results) - Dropping nonwhites increases estimates of
efficacy - Separate examination compared to Medicaid
eligible, other control group - More effective relative to Medicaid eligible
control, stronger impacts - FE similar to OLS, except for extension waivers
- WLS estimates slightly smaller than OLS/FE
22Teens
- No statistically significant impact on sexual
activity - Any-type waiver decreases teen pregnancy,
motherhood, combined abortion, miscarriage
still births - Income eligibility waivers decrease pregnancy,
teen mother hood - Extension waivers decrease teen pregnancy
23Rural/Urban Differences
24Future Directions
- BC consistency of use sensitive to outliers?
- More work on unplanned/unwanted pregnancy
- Other pregnancy outcomes (spacing, prenatal care,
low birth weight / premature birth) - Males
- Other aspects of policy (enrollment practices
etc) - Older women
- Other reproductive health policies, provider
availability (addition of Guttmacher Institute
data) - Cost-benefit ratios
25Conclusions
- Effective at reducing pregnancies, combined
abortions, miscarriages stillbirths, bigger
effects for teens - No increased sexual activity
- Results apply to all eligible young women, not
just participants - Robust to sampling assumptions
- DDD fixed effects provide strong support for
waivers