The Efficacy of Medicaid Family Planning Waivers On Young Women: Difference-in-Difference Evidence from National Microdata - PowerPoint PPT Presentation

1 / 25
About This Presentation
Title:

The Efficacy of Medicaid Family Planning Waivers On Young Women: Difference-in-Difference Evidence from National Microdata

Description:

The Efficacy of Medicaid Family Planning Waivers On Young Women: Difference-in-Difference Evidence from National Microdata Amy M. Wolaver Bucknell University – PowerPoint PPT presentation

Number of Views:152
Avg rating:3.0/5.0
Slides: 26
Provided by: Department1059
Category:

less

Transcript and Presenter's Notes

Title: The Efficacy of Medicaid Family Planning Waivers On Young Women: Difference-in-Difference Evidence from National Microdata


1
The 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

2
Alternative 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

3
Introduction
  • 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)

4
Family 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

5
Medicaid 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

6
Political 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

7
Waiver 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

8
Previous 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)

9
Methods
  • 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

10
Methods, 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

11
Regression 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

12
Regression 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

13
Data
  • 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

14
Outcomes
  • 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

15
Policy 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
16
Waiver/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
17
DDD 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.

18
DDD 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.

19
DDD 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.

20
General 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

21
Robustness 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

22
Teens
  • 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

23
Rural/Urban Differences
24
Future 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

25
Conclusions
  • 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
Write a Comment
User Comments (0)
About PowerShow.com