Duke 2008 | ASHE | Equity and Efficiency in Health and Healthcare

Medicaid is a major source of health care coverage for poor women of reproductive age. Medicaid family planning waivers have become increasingly popular with states since the first waiver was approved in 1994. States find the waivers advantageous in part because the matching rate for federal funds is higher for family planning services than other services. Typically, these waivers bring more women into eligibility for coverage of these limited services (forms of contraception, sexually transmitted disease testing, gynecological examinations, counseling/education about contraception etc?). The scant amount of scholarly research on these programs has found that they are at least cost-neutral and probably cost-saving at the federal level in that they prevent the costly pregnancies which bring many women into enrollment and coverage under the regular auspices of Medicaid. Most of the research on this topic compares overall program costs before and after the waiver have passed within a state, but no comprehensive, comparative study has been done on the program using national microdata.

The main outcomes of interest are contraception use, unwanted pregnancies, sexual activity, behavior during pregnancy (substance use), pregnancy timing (age, timing in between pregnancies), and pregnancy outcomes (low birth weight, gestational age, number of children, and reported pregnancies resulting in no live birth to proxy for pregnancy terminations). While 8 states also cover men with these services, this study will focus on outcomes for females. There are two additional dimensions of interest. First, do the impacts of these waivers differ depending on the rural/urban status of women? Women may differ in attitudes/acceptance of contraceptive services by rural/urban status. Certainly access to providers differs geographically, with women in rural and inner cities having less access to medical professionals. Second, which plan features result in the best outcomes? States have employed a variety of plan designs to extend eligibility to more women, from extending postpartum coverage to Medicaid recipients to any loss of Medicaid coverage to raising income eligibility thresholds for all women for family planning services. Some states prohibit coverage of teenagers. The efficacy of the waivers will likely vary with these program variations.

This paper will test whether outcomes differ for low income women in states with Family Planning Medicaid waivers to states without waiver programs using both the 1979 (for older women) and 1997 (for younger women) National Longitudinal Surveys of Youth geocode data. There is considerable cross-sectional and longitudinal variation in implementation of these policies over the past 13 years, with 26 waivers currently approved (Guttmacher Institute 2007). Difference-in-difference estimates will be used to identify the impact of the policy on family-planning related effects. In addition, the use of longitudinal data will allow for fixed-effects controls for individual heterogeneity in fertility preferences.