Medicaid and Pregnant Women: Who Is Being Enrolled and When

Article excerpt

INTRODUCTION

During the late 1980s, Congress focused heavily on expanding Medicaid eligibility at the State level for low-income pregnant women. By 1990, States were required to extend Medicare coverage to all pregnant women with family incomes below 133 percent of the Federal poverty level (FPL), with the option to cover up to 185 percent of FPL. States were also permitted to drop the assets test and expedite the eligibility process in other ways. Before the changes, Medicaid coverage for pregnant women had been closely linked to the Aid to Families with Dependent Children (AFDC) program, and State AFDC programs generally used income standards for eligibility that were considerably lower than the FFL. As a result, only 4 out of 10 women of reproductive age with family income below the FPL were covered by Medicaid in 1984 (Gold and Kenney, 1985). In expanding coverage, Congress intended to enroll more low-income pregnant women in Medicaid and to improve enrollment rates during the early stages of pregnancy. The idea was to improve access to adequate prenatal care, the assumption being that early continual prenatal care would have a positive effect on birth outcomes, including the reduction of infant mortality and morbidity rates for the low-income population.

This article focuses on the effect of the Medicaid expansions on pregnant women in four States--California, Georgia, Michigan, and Tennessee--from 1987 through 1991. It is primarily a descriptive analysis based on Medicaid enrollment and claims data from these States and case study data (Dubay et al., 1995). This analysis was intended to address two major questions (and several followup questions):

* What is the extent of expansion in Medicaid-covered deliveries by eligibility group?--What proportion of Medicaid-covered deliveries can be attributed to extending Medicaid to low-income women by measuring their family income against some percentage of the poverty level, as opposed to the traditional approach of providing Medicaid coverage through eligibility for AFDC cash assistance or State programs for the medically needy? What is the impact of other eligibility changes, including the extension of Medicaid coverage to undocumented aliens? Are there differences in age, race, and geographic residence by eligibility group?

* Were States successful in enrolling pregnant women early in their pregnancies?--What is the impact of improvements made to the enrollment system, such as the outstationing of eligibility workers or the adoption of presumptive eligibility? What proportion of poverty-related pregnant women were enrolled in Medicaid during the first trimester of pregnancy? What was the success in early enrollment with other eligibility groups?

Our report begins with a review of the legislation defining Medicaid coverage of low-income pregnant women and the reported effects of expanded eligibility. The data and methods through which we identified Medicaid deliveries are discussed, as is the development of Medicaid eligibility requirements and eligibility determination procedures in the four States over the study period. The presentation of results includes data on the number of deliveries financed by Medicaid in 1987 and 1991 for the study States; an analysis of the somewhat surprising differences in growth rates among the States, which includes an assessment of growth disaggregated by eligibility group to isolate the effects of the expansion effort; and a description of changes in the demographic characteristics of women delivering under Medicaid. The article concludes with an analysis of the timing of Medicaid enrollment for pregnant women.

BACKGROUND

The financial standards for pregnant women were first changed through the Omnibus Budget Reconciliation Act (OBRA) of 1986, which gave States the option to cover all pregnant women with family income below the FPL. In 1987, States were given the option to extend coverage to pregnant women up to 185 percent of the FPL. …