The Impact of Medicaid Managed Care on Pregnant Women in Ohio: A Cohort Analysis

Abstract

Objective. To examine the impact of mandatory HMO enrollment for Medicaidcovered pregnant women on prenatal care use, smoking, Cesarean section (C-section) use, and birth weight. Data Sources/Study Setting. Linked birth certificate and Medicaid enrollment data from July 1993 to June 1998 in 10 Ohio counties, 6 that implemented mandatory HMO enrollment, and 4 with low levels of voluntary enrollment (under 15 percent). Cuyahoga County (Cleveland) is analyzed separately; the other mandatory counties and the voluntary counties are grouped for analysis, due to small sample sizes. Study Design. Women serve as their own controls, which helps to overcome the bias from unmeasured variables such as health beliefs and behavior. Changes in key outcomes between the first and second birth are compared between women who reside in mandatory HMO enrollment counties and those in voluntary enrollment counties. County of residence is the primary indicator of managed care status, since, in Ohio, women are allowed to ''opt out'' of HMO enrollment in mandatory counties in certain circumstances, leading to selection. As a secondary analysis, we compare women according to their HMO enrollment status at the first and second birth. Data Collection/Extraction Methods. Linked birth certificate/enrollment data were used to identify 4,917 women with two deliveries covered by Medicaid, one prior to the implementation of mandatory HMO enrollment (mid-1996) and one following implementation. Data for individual births were linked over time using a scrambled maternal Medicaid identification number. Principal Findings. The effects of HMO enrollment on prenatal care use and smoking were confined to Cuyahoga County, Ohio's largest county. In Cuyahoga, the implementation of mandatory enrollment was related to a significant deterioration in the timing of initiation of care, but an improvement in the number of prenatal visits. In that county also, women who smoked in their first pregnancy were less likely to smoke during the second pregnancy, compared to women in voluntary counties. Women residing in all the mandatory counties were less likely to have a repeat C-section. There were no effects on infant birth weight. The effects of women's own managed care status were inconsistent depending on the outcome examined; an interpretation of these results is hampered by selection issues. Changes over time in outcomes, both positive and negative, were more pronounced for African American women. Conclusions. With careful implementation and attention to women's individual differences as in Ohio, outcomes for pregnant women may improve with Medicaid 825

Maintaining Insurance Access under Trump — A Strategy

“…There are some national studies with positive findings, especially with respect to access to a usual source of care (see Table 3 Illustrating the complexity and state-specific nature of the access issue are a series of studies that examine beneficiary access to prenatal care. A couple of these studies find improved access (38,51). At the same time, however, there are several studies that suggest Medicaid managed care actually reduces beneficiary access (1,16,71).…”

“…There are several studies that examine whether enrollment in a managed care delivery system improves the likelihood that a pregnant beneficiary will have a healthy child. Most such studies find that there is no impact on either birthweight or infant mortality rates (16,17,25,38,44,51). This seems to be true whether the managed care initiative improved access to prenatal care (38,51) or resulted in reduced access to prenatal care (16).…”

“…Most such studies find that there is no impact on either birthweight or infant mortality rates (16,17,25,38,44,51). This seems to be true whether the managed care initiative improved access to prenatal care (38,51) or resulted in reduced access to prenatal care (16). Aizer et al offer an even more troubling finding: Their study of California's managed care initiative suggests that managed care enrollees actually had higher rates of low-birthweight babies and neonatal deaths (1).…”

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“…12 The advent of Medicaid managed care restructured the way in which health services were organized and financed for many poor women. [13][14][15] Other initiatives that were more variable from state-to-state and locality-to-locality were efforts to increase the number of health care providers in low-income areas, 16 expansions in the availability of neonatal intensive care, 17 and efforts to promote regular perinatal risk assessment and referral. 18 Generally, studies of disparities in maternal and infant health have focused on individual characteristics, such as a mother's race/ethnicity, income, or education.…”

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“…Gruber and Owings (1996) document that C-section rates respond to changes in the volume of births over time. 49 To address this concern, I control for the number of birth discharges at each hospital in each calendar year. Therefore, my instrumental variables will not incorporate the unobserved effect of the volume of births on C-section use.…”