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THE EFFECTS OF WELFARE REFORM ON LOW INCOME WOMEN’S INSURANCE STATUS AND PRENATAL CARE USE

THE EFFECTS OF WELFARE REFORM ON LOW INCOME WOMEN’S INSURANCE STATUS AND PRENATAL CARE USE. REGION V AND VII MCH CONFERENCE CHICAGO, ILLINOIS APRIL 22, 2002. Arden Handler, DrPH Deborah Rosenberg, PhD Kathleen Adams, PhD Meagan Zimbeck, MPH. Welfare Reform.

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THE EFFECTS OF WELFARE REFORM ON LOW INCOME WOMEN’S INSURANCE STATUS AND PRENATAL CARE USE

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  1. THE EFFECTS OF WELFARE REFORM ON LOW INCOME WOMEN’S 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 • 5year 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 <100% 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 womenabout eligibility

  10. Welfare Reform, Pregnancy and Medicaid • As a result of Medicaid expansions of the late 1980’s and 1990’s 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)

  12. 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 Total (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

  13. 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)

  14. 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. Alaska Florida Georgia Maine New York (excludes NYC) Oklahoma S. Carolina Washington West Virginia Welfare Reform, Insurance Status and Prenatal Care Use- PRAMS States Included in the Analysis

  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. 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 Welfare Reform, Insurance Status and Prenatal Care Use

  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%

  39. 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 SSIor 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 women’s 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

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