Principal investigator: Bruno Benevit
Authors: Janet Currie and Jonathan Gruber
Location of the Intervention: United States
Sample Size: 526.830 individuals
Sector: Health Insurance
Primary Variable of Interest: Infant mortality, low birth weight newborns
Type of Intervention: Eligibility for health insurance coverage
Methodology: OLS and IV
Summary
The expansion of healthcare services is a topic relevant to many countries, prompting analysis of the priority needs of various population groups. A critical aspect for the healthcare system concerns the expansion of public health insurance eligibility in the United States. This article examines whether changes in the program's eligibility criteria have significantly impacted this expansion. Medicaid Changes that occurred in the United States between 1979 and 1992 resulted in improvements in neonatal and prenatal health markers. Using OLS and IV methodologies, the results demonstrated that the changes in Medicaid The study found that the eligibility of pregnant women for the program increased dramatically, that there was a decrease in the rates of low birth weight newborns and infant mortality, and that the groups affected by the targeted changes in the program were most positively impacted. The study also estimates that the cost per life saved was between US$840.000 and US$4,2 million.
- Policy Problem
Infant mortality rate and the incidence of low birth weight newborns are two of the main indicators of child health (Currie and Gruber, 1996). The United States had one of the highest infant mortality rates in the industrialized world in the 1990s, with 9 infant deaths per 1.000 births (US House of Representatives 1992(pp. 1116-17). This rate may reflect a large number of unhealthy newborns. Therefore, it is essential to assess the determinants related to this situation, observing how policies to expand access to health service coverage affect newborns, what costs are associated with such policies, and how priority groups adopt such policies.
- Implementation and Evaluation Context
Between the 1980s and 80s, there was a rapid expansion in the eligibility of pregnant women for Medicaid, with the goal of increasing the use of prenatal care. Until the early 90s, eligibility for the Medicaid It was linked to receiving social security payments under the program. Aid to Families with Dependent Children (AFDC). This linkage had the effect of limiting eligibility to very low-income women in single-parent families, making access to the program very restrictive. Recent extensions of eligibility to other groups provide a case study on whether changes in health insurance eligibility can actually improve child health.
- Policy/Program Details
O Medicaid It is a federal program in partnership with the states that provides health insurance to low-income populations. Eligibility for health coverage through this program for women and children has historically been linked to participation in the AFDC. This link has led to restricted access to Medicaid restricted access to the program. This was due to several aspects of the AFDC program design, whether it was due to restrictions on social benefits to only families headed by women, such as the program AFDC – Unemployed Parents, or due to very low and heterogeneous income bracket parameters among the states.
Due to these restrictions, states had the option to extend the benefits of Medicaid to some groups of pregnant women who were not in the AFDC throughout the period from 1979 to 1992. Such eligibility changes during this era can be divided into two types. The first type was categorized as “targeted eligibility” changes, and considers the expansion of coverage to groups covered by the AFDC in a less restrictive way with respect to the beneficiaries' family structure and to individuals who had large medical expenses. The second type was categorized as “broad eligibility” changes, and concerns changes that allowed states to expand access to all women above the previous minimum income bracket. The target audiences of both changes notably differed in their socioeconomic contexts.
- Method
The article includes several analyses regarding the expansion of the program's eligibility. Medicaid. The database used for the primary analysis consisted of aggregated newborn data from all US states available in Vital Statistics between the years 1979 and 1992. The study uses an eligibility index of Medicaid as an intervention variable, representing the fraction of women aged 15 to 44 in each state and the year in which they would be eligible for Medicaid coverage in case of pregnancy.
To control for potential bias arising from omitted characteristics specific to each state or year, an instrumental variable was adopted for the eligible actual fraction. This instrument was created from a sample of 3.000 women from... Current Population Survey (CPS) for each year simulating the eligibility of each woman from each state to control for differences in the legislative environments of each state. In addition to the instrumental variable, the study also employs the ordinary least squares (OLS) method.
The analyses were disaggregated by type of eligibility change. The first type consists of targeted changes, encompassing specific groups that gained access to eligibility through the easing of access to... Medicaid linked to other social programs. The second type consists of broad changes, where access to [social programs] was expanded. Medicaid for all women with income equivalent to up to 185% of the federal poverty level.
The initial analysis considered the outcome variables of low birth weight (less than 2.500 grams) and infant mortality rate in each state and year. Estimates were made in relation to overall eligibility, targeted eligibility changes, and broad eligibility changes. Additionally, these results were re-estimated using robust regression techniques to control for observational effects. outliers through the adoption of weights and other specifications considering additional variables.
The second analysis verifies which observable characteristics are predictive of health coverage by Medicaid Using linear probability models. The dataset consists of 526.830 observations for the period 1979 to 1992. The observations for directed and broad changes cover the period 1987 to 1992. All regressions include a full set of state and year dummies.
The third analysis examines the efficiency of the allocated policy resources. For this purpose, data on total expenditures on physicians, hospital inpatient departments, and hospital and other clinic outpatient services were used for all non-disabled children and non-disabled/non-elderly adults. Expenditures were normalized using the state's female population aged 15 to 44. Expenditures were normalized and deflated to thousands of 1986 dollars.
Finally, the fourth analysis verifies whether eligibility had an effect on the demand for prenatal care before the third month of pregnancy due to targeted changes. This analysis used data from 1979 to 1990 from... National Longitudinal Survey of Youth (NLSY) regarding the month in which prenatal care began.
- Main results
The results of the analysis regarding the indicators for newborns indicate that the increase in eligibility criteria for Medicaid These changes resulted in a 1,9% and 8,5% decrease in the incidence of low birth weight and infant mortality rates, respectively. Evaluating the effect of eligibility changes in a disaggregated manner, the results indicate that targeted eligibility had larger and more significant effects compared to broad eligibility. Robustness analyses showed small variations in the magnitude of the effects, but did not alter the inference regarding the impact on the infant mortality rate.
Estimates from the analysis regarding the predictive characteristics of coverage of Medicaid Studies show that general eligibility had smaller effects than those identified in other social programs. The effects of targeted eligibility were again higher, while no effects of broad eligibility were identified. Overall, the people most likely to be covered by the program are non-white, single women with children and low incomes.
The main result regarding the effect of expanding eligibility for Medicaid Regarding healthcare spending, a significant positive effect was observed when considering broad eligibility. Individuals with broad eligibility experienced greater effects compared to those with targeted eligibility, an unexpected result for the authors.
Cost-benefit analyses indicate that the cost of saving a life through targeted eligibility changes was US$840.000, while the cost of saving a life through broad eligibility changes was US$4,2 million. Overall, the authors find that the costs associated with targeted eligibility were more efficient compared to estimates of the value per life saved presented in the literature.
The results of the analysis on the probability of delay in prenatal care indicate that eligibility directed to Medicaid This reduces the probability of delay by almost half when considering the instrumental outcome variable.
- Lessons in Public Policy
This article evaluated how the expansion of eligibility for the program Medicaid The outbreak that occurred in the US between 1979 and 1992 impacted prenatal care and newborn health indicators.
Using OLS methods and instrumental variables, three main conclusions were identified. First, the changes dramatically increased Medicaid eligibility for pregnant women, but this occurred heterogeneously across states. Second, the changes reduced the incidence of infant mortality and low birth weight babies. Third, targeted changes in eligibility... Medicaid These changes had a much greater impact on birth rates than broader eligibility expansions, a phenomenon explained by the income disparity between the groups affected by such changes. Finally, it was estimated that the targeted changes cost the program... Medicaid $840.000 per life saved. Various methods for measuring this value found in the literature allow for different interpretations regarding the policy's effectiveness.
References
Currie, J. and Gruber, J. (1996), “Saving Babies: The Efficacy and Cost of Recent Changes in the Medicaid Eligibility of Pregnant Women”, Journal of Political Economy, Vol. 104 No. 6, pp. 1263–1296.
