Data Highlights | References | Tables

Background

During the 1980s and 1990s, policymakers and program planners focused on increasing the use of prenatal care by improving access to it. In particular, Medicaid eligibility was greatly expanded during this time under the assumption that reducing the number of uninsured pregnant women would lead to improved access to prenatal care. Title XIX of the Social Security Act, known as Medicaid, became law in 1965 as a jointly funded federal and state cooperative venture to provide adequate medical care coverage to eligible needy persons, including low-income, single-parent families with children.¹ Between 1986 and 1990, Congress enacted major expansions of the federal eligibility requirements for Medicaid to include more lower-income pregnant women.^1,2 By 1989, state Medicaid programs were required to cover pregnant women with family incomes up to 133% of the federal poverty level, regardless of marital status or whether they already had children. Further, states had the option of expanding coverage to pregnant women with family incomes up to 185% of the poverty level.

In addition, Congress indirectly opened the door for expanding service coverage for pregnant women by permitting states to implement "presumptive eligibility," "outstationing," and "continuous eligibility." Presumptive eligibility allowed providers to extend temporary Medicaid coverage so that pregnant women could receive prenatal care immediately, outstationing allowed women and children to sign up at providers' offices instead of solely at welfare offices, and continuous eligibility allowed women to retain Medicaid coverage, despite fluctuations in their income, throughout the pregnancy.³ The federal government also began providing federal matching funds to states to provide coverage for a broader set of services for pregnant women, including case management and psychosocial risk assessment.

Although implementation of the new policies varied considerably across the states, between 1985 and 1990, the average state income eligibility level for pregnant women rose from 55% to 159% of the poverty level, and many states streamlined the enrollment process, implemented presumptive eligibility, outstationed enrollment workers in prenatal care sites, established toll-free hotlines, enhanced benefits for pregnant women, and increased the fees paid by Medicaid to prenatal care providers.³ As a consequence of these Medicaid expansions, the percentage of live births paid for by Medicaid increased rapidly, from less than 15% in 1985 to 32% in 1991,⁴ reaching 37% of live births in 2001.⁵

Despite efforts to expand Medicaid coverage and facilitate enrollment, many eligible women do not enroll until the second or third trimester of their pregnancies, thus delaying initiation of prenatal care.^6,7 Women with Medicaid-covered deliveries have also been found to have fewer prenatal care visits than women with other health insurance coverage, resulting in higher rates of inadequate prenatal care as measured by commonly used indexes of prenatal care adequacy.^7,8 The delay in initiating prenatal care may be a key reason why Medicaid and uninsured women have lower average levels of care.⁸

Although use of prenatal care may not be as high among Medicaid-covered women when compared with privately insured women, women who would have otherwise been uninsured had improved access to prenatal care under the expansions. Recent studies of national and state-level natality files have attributed at least part of the improvement in prenatal care use in the first half of the 1990s to the Medicaid expansions implemented in the late 1980s and early 1990s.^9–11 However, Howell's¹² review of the evidence on the impact of Medicaid expansions indicates that improvements in early initiation of and adequate levels of prenatal care were modest, and that the improvements were found only in some states and only for some groups affected by the expansions. Furthermore, significant racial and ethnic disparities have been found in the use of prenatal care among Medicaid beneficiaries. Compared with non-Hispanic white Medicaid beneficiaries, non-Hispanic black and Hispanic Medicaid beneficiaries were less likely to receive prenatal services that the woman initiates, discretionary services, and services potentially requiring specialized follow-up care.¹³

Recent changes in social welfare programs may have slowed or threatened further improvements in prenatal care use. In particular, the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 had the unintended effect of reducing health insurance coverage of low-income women prior to pregnancy¹⁴ and thereby may have stalled or reversed improvements in the receipt of early and adequate prenatal care among low-income women in the United States. PRWORA replaced Aid to Families with Dependent Children (AFDC) with the Temporary Assistance for Needy Families (TANF) program. The new program restricts welfare tenure, imposes new work requirements, and uncouples welfare and Medicaid eligibility. The dramatic decreases in welfare caseloads following implementation of PRWORA were accompanied by reductions in Medicaid enrollments and increased numbers of uninsured people.^15,16 Because welfare recipients are primarily mothers and children, women of childbearing age have been particularly vulnerable to becoming uninsured.^17,18 More than 13% of pregnant women were uninsured in 1999, up from 11% in 1990.¹⁹

For uninsured women who become pregnant and meet the expansion income requirements, Medicaid has been an important safety net. However, given that many women who must be pregnant to become eligible enroll after their first trimester, the question arises as to whether the gains in early and adequate prenatal care use seen in the 1980s and early to mid-1990s have stalled or been reversed as a result of PRWORA.

On the other hand, the implementation of the State Children's Health Insurance Program (SCHIP) may have improved prenatal care access among pregnant teens and other pregnant women. SCHIP, Title XXI of the Social Security Act, was established in the Balanced Budget Act of 1997 to provide block grants to states for expanding health insurance coverage to low-income children by expanding Medicaid, developing new "separate" child health programs, or a combination of both approaches. Nearly 4 million children were covered under the program as of December 2003.²⁰ Nine states have received waivers to use SCHIP monies to cover other low-income groups including parents of SCHIP children (Arizona, California, Illinois, Minnesota, New Jersey, Oregon, Rhode Island, and Wisconsin), pregnant women (Colorado, New Jersey, Oregon, and Rhode Island), and certain childless adults (Arizona, Oregon).²¹

PRAMS provides data on whether women had Medicaid coverage for prenatal care and whether they were able to initiate prenatal care as early as desired. States can use these data to monitor the impact of welfare policy changes, such as PRWORA, and expansions or coverage changes in their Medicaid and SCHIP. Healthy People 2010 has prioritized increasing the proportion of persons with health insurance and the proportion of insured persons with access to clinical preventive services.²² Assessing the extent of Medicaid coverage and its effect on prenatal care will help identify whether we are moving closer to these Healthy People 2010 objectives.

Data Highlights

• For 2002, the prevalence of Medicaid coverage for prenatal care ranged from 7.0% (Rhode Island) to 53.3% (Louisiana).
  
  
• During 1993–2002, the prevalence of Medicaid coverage for prenatal care increased in 1 state (Alaska) and decreased in 3 states (Alabama, Florida, and West Virginia).
  
  
• During 2000–2002, the prevalence of Medicaid coverage for prenatal care increased in 1 state (Nebraska).

References

1. Centers for Medicare and Medicaid Services Office of the Actuary. Health Care Financing Review, Medicare and Medicaid Statistical Supplement, 2001, Overview [Brief Summaries of Medicare and Medicaid Title XVIII and Title XIX of the Social Security Act as of November 1, 2002]. Washington, DC: U.S. Department of Health and Human Services; 2002.
   
   
2. Loranger L, Lipson D. Medicaid Expansions for Pregnant Women and Children. Washington, DC: Alpha Center; 1995.
   
   
3. Gold RB, Singh S, Frost J. The Medicaid eligibility expansions for pregnant women: evaluating the strength of state implementation efforts. Family Planning Perspectives 1993;25(5):196–207.
   
   
4. Singh S, Gold RB, Frost JJ. Impact of the Medicaid eligibility expansions on coverage of deliveries. Family Planning Perspectives 1994;26(1):31–33.
   
   
5. National Governors' Association (NGA) Center for Best Practices. MCH Update: States Protect Health Care Coverage During Recent Fiscal Downturn. Washington, DC: National Governors' Association; 2005.
   
   
6. Egerter S, Braveman P, Marchi K. Timing of insurance coverage and use of prenatal care among low-income women. American Journal of Public Health 2002;92(3):423–427.
   
   
7. Katz SJ, Armstrong RW, LoGerfo JP. The adequacy of prenatal care and incidence of low birthweight among the poor in Washington State and British Columbia. American Journal of Public Health 1994;84(6):986–991.
   
   
8. Kaestner R. Health insurance, the quantity and quality of prenatal care and infant health. Inquiry 1999;36(2):162–175.
   
   
9. Dubay L, Joyce T, Kaestner R, Kenney GM. Changes in prenatal care timing and low birth weight by race and socioeconomic status: implications for the Medicaid expansions for pregnant women. Health Services Research 2001;36(2):373–398.
   
   
10. Currie J, Grogger J. Medicaid expansions and welfare contractions: offsetting effects on prenatal care and infant health? Journal of Health Economics 2002;21(2):313–335.
    
    
11. Rittenhouse DR, Braveman P, Marchi K. Improvements in prenatal insurance coverage and utilization of care in California: an unsung public health victory. Maternal and Child Health Journal 2003;7(2):75–86.
    
    
12. Howell EM. The impact of the Medicaid expansions for pregnant women: a synthesis of the evidence. Medical Care Research and Review 2001;58(1):3–30.
    
    
13. Gavin NI, Adams EK, Hartmann KE, Benedict MB, Chireau M. Racial and ethnic disparities in the use of pregnancy-related health care among Medicaid pregnant women. Maternal and Child Health Journal 2004;8(3):113–126.
    
    
14. Adams EK, Gavin NI, Handler A, Manning W, Raskind-Hood C. Transitions in insurance coverage from before pregnancy through delivery in nine states, 1996–1999. Health Affairs 2003;22(1):219–229.
    
    
15. Ellwood M. The Medicaid Eligibility Maze: Coverage Expands, but Enrollment Problems Persist: Findings From a Five State Study. Cambridge, MA: Mathematica Policy Research; 1999.
    
    
16. Holahan J, Pohl MB. Recent changes in health policy for low-income people in Washington. Assessing the New Federalism. State Update Number 24. Washington, DC: Urban Institute; 2002.
    
    
17. Gold RB. Implications for family planning of post-welfare reform insurance trends. The Guttmacher Report 1999;2(6):1–7.
    
    
18. Kaestner R, Kaushal N. Welfare reform and health insurance coverage of low-income families. Journal of Health Economics 2003;22(6):959–981.
    
    
19. Thorpe KE, Flome J, Joski P. The Distribution of Health Insurance Coverage Among Pregnant Women, 1999. Atlanta, GA: Emory University; 2001.
    
    
20. Smith VK, Rousseau DM, O'Malley M. SCHIP Program Enrollment: December 2003 Update. Washington, DC: Kaiser Commission on Medicaid and the Uninsured; 2004.
    
    
21. Centers for Medicare and Medicaid Services, Center for Medicaid State Operations, Family and Children's Health Program Group. State Children's Health Insurance Program (SCHIP) Approved Section 1115 Demonstration Projects As of November 17, 2004. Washington, DC: U.S. Department of Health and Human Services.
    
    
22. U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd Edition. Washington, DC: U.S. Government Printing Office; 2000.

 

Prevalence of Medicaid Coverage for Prenatal Care, 2002

State	Respondents	Percent†	Standard Error	95% CI‡
Alabama	1,529	47.1	0.8	45.5–48.8
Alaska	1,595	42.4	1.4	39.7–45.2
Arkansas	1,927	48.1	1.6	45.0–51.1
Colorado	2,271	31.6	1.3	29.1–34.1
Florida	2,006	41.6	1.6	38.5–44.8
Hawaii	1,799	24.6	1.1	22.5–26.9
Illinois	1,921	42.2	1.2	39.9–44.6
Louisiana	1,663	53.3	1.4	50.6–55.9
Maine	1,130	37.2	1.7	34.0–40.5
Maryland	1,445	25.2	1.8	21.9–29.0
Michigan	1,536	35.9	1.4	33.2–38.7
Minnesotaa	1,139	29.4	1.7	26.3–32.8
Montana	1,034	34.7	1.5	31.9–37.7
Nebraska	1,873	38.4	1.3	35.9–41.0
New Jerseyb	937	22.9	1.3	20.4–25.6
New Mexico	1,543	48.1	1.3	45.5–50.7
New Yorkc	1,212	26.9	1.7	23.7–30.4
North Carolina	1,525	41.0	1.6	38.0–44.1
North Dakota	900	23.3	0.9	21.7–25.1
Ohio	1,360	31.3	1.6	28.3–34.5
Oklahoma	1,845	44.2	1.8	40.7–47.8
Rhode Island	1,399	7.0	0.7	5.7–8.6
South Carolina	1,393	49.5	2.1	45.3–53.7
Utah	1,559	24.9	1.4	22.3–27.8
Vermont	1,099	39.1	1.5	36.3–42.0
Washington	1,504	30.3	1.6	27.4–33.5
West Virginia	1,683	52.0	1.7	48.7–55.4
All PRAMS states§	40,827	36.8	0.4	36.1–37.6
† 2002 state range is 7.0–53.3%. ‡ Confidence interval. § Aggregate of the 27 PRAMS states. a Data represent Minnesota births from May–December 2002. b Data represent New Jersey births from July–December 2002. c Data exclude New York City.

 

Prevalence of Medicaid Coverage for Prenatal Care, 2002

 

Prevalence of Medicaid Coverage for Prenatal Care, 1993–2002

State	1993 (%)	1994 (%)	1995 (%)	1996 (%)	1997 (%)	1998 (%)	1999 (%)	2000 (%)	2001 (%)	2002 (%)	P value for trend#
Alabama	48.7	48.4	49.5	48.4	48.1	46.7	45.8	46.0	47.3	47.1	0.001*
Alaska	31.3	33.3	32.6	32.4	36.0	35.2	39.0	41.1	40.8	42.4	0.000**
Arkansas	—	—	—	—	44.6	45.4	44.5	43.9	49.0	48.1	0.046*
Colorado	—	—	—	—	—	27.2	28.7	28.7	28.1	31.6	0.049*
Florida	46.3	44.9	44.5	40.0	40.9	37.0	35.9	34.6	37.4	41.6	0.000**
Hawaii	—	—	—	—	—	—	—	24.0	24.1	24.6	0.640
Illinois	—	—	—	—	36.4g	32.6	35.4	35.3	39.0	42.2	0.000**
Louisiana	—	—	—	—	—	47.6	49.1	47.6	51.9	53.3	0.001**
Maine	36.9	35.8	36.8	35.5	33.2	34.5	32.7	35.3	35.2	37.2	0.584
Maryland	—	—	—	—	—	—	—	—	23.4d	25.2	# #
Michigan	—	—	—	—	—	—	—	—	35.5e	35.9	# #
Minnesota	—	—	—	—	—	—	—	—	—	29.4a	# #
Montana	—	—	—	—	—	—	—	—	—	34.7	# #
Nebraska	—	—	—	—	—	—	—	31.8	32.5	38.4	0.000**
New Jersey	—	—	—	—	—	—	—	—	—	22.9b	# #
New Mexico	—	—	—	—	—h	43.8h	49.9	48.0	49.4	48.1	0.037*
New Yorkc	28.4	29.4	26.9	24.9	26.7	24.0	23.9	24.9	24.8	26.9	0.069
North Carolina	—	—	—	—	45.5i	43.1	41.6	41.4	41.8	41.0	0.134
North Dakota	—	—	—	—	—	—	—	—	—	23.3	# #
Ohio	—	—	—	—	—	—	28.5	26.2	28.1	31.3	0.133
Oklahoma	37.7	39.3	40.9	38.4	31.5	31.4	30.9	40.3	41.5	44.2	0.103
Rhode Island	—	—	—	—	—	—	—	—	—	7.0	# #
South Carolina	50.4	49.8	50.1	52.6	48.9	51.1	52.0	49.0	53.6	49.5	0.676
Utah	—	—	—	—	—	—	21.5	23.3	20.8	24.9	0.202
Vermont	—	—	—	—	—	—	—	—f	37.0f	39.1	# #
Washington	—	38.4	37.2	33.9	29.1	28.1	28.9	26.9	29.4	30.3	0.000**
West Virginia	53.9	56.1	60.0	57.0	55.4	52.1	53.4	53.5	53.3	52.0	0.008*
# Based on a test for linear trend using logistic regression. * p value is less than 0.05. ** p value is less than 0.001. # # < 3 years of data available; test for linear trend not applicable. a Data represent Minnesota births from May–December 2002. b Data represent New Jersey births from July–December 2002. c Data exclude New York City. d Data represent Maryland births from February–December 2001. e Data represent Michigan births from July–December 2001. f Data represent Vermont births from October 2000–December 2001. g Data represent Illinois births from June–December 1997. h Data represent New Mexico births from July 1997–December 1998. i Data represent North Carolina births from July–December 1997.