The impact of the Medicaid expansions for pregnant women: a synthesis of the evidence.

This article provides a comprehensive review of the published literature on the impact of expanding Medicaid for pregnant women to higher income groups of women. The major expansions took place between April 1987 and July 1989. These studies show evidence that new groups of pregnant women received health insurance coverage through Medicaid, and that some women received improved prenatal care services. The evidence is much weaker that the expansions led to improved birth outcomes. The fact that other parts of the developed world have experienced sustained declines in infant mortality without expansions of health insurance coverage points to the complexity in the origins of poor birth outcomes. It is possible that the benefits from the Medicaid expansions were merely victories in small battles within a much larger war that remains to be won.

Perinatal substance abuse treatment. Findings from focus groups with clients and providers.

Thirty-three focus groups were conducted with pregnant women in substance abuse treatment and their providers in order to identify factors in women's lives that facilitate and hamper their treatment process and successful program components to address the needs of this high-risk population. The focus groups were conducted as part of a larger evaluation of demonstrations funded by the Health Care Financing Administration. From the 88 women in the focus groups we received a picture of their troubled lives and the events that led to their participation in the programs. The women had difficult childhoods, and currently had weak support networks and difficult relationships with male partners, many of whom were substance abusers. Most had children, which complicated getting into and staying in treatment. However, fear of losing custody of children was a major motivator for treatment. Important components of successful programs included: (a) the development of interorganizational linkages between various governmental agencies, especially child protection systems, prenatal care providers, and substance abuse treatment agencies and providers; (b) outreach and systems for identifying pregnant substance abusers through provider education and routine screening; and (c) intensive case management, necessary to link women to the many services they needed in order to obtain treatment, such as child care, transportation, and housing.

A review of recent findings on substance abuse treatment for pregnant women.

Recent years have brought an increased interest in the treatment needs of pregnant substance abusers. This article reviews the literature on this subject, providing an overview of what is known about the prevalence of substance abuse during pregnancy; the factors in women's lives, especially pregnant women, that lead to substance abuse and that facilitate and impede treatment success; and the components of successful treatment programs. The prevalence of prenatal illicit drug use is known to be about 5% of all pregnant women nationwide, with higher rates for selected subgroups. Local studies have shown much higher rates. Substance abuse is associated with poverty, with the substance abuse of significant others, and with family violence. Perinatal substance abusers experience poorer birth outcomes. The negative consequences for babies do not stop at birth; home environments may be chaotic and often children are removed from their mother's care if substance abuse continues after birth. While the literature on prevalence, correlates, and outcomes of perinatal substance abuse is plentiful, there continues to be sparse information on successful treatment approaches. Sample sizes are small and there are few studies with adequate comparison groups. The small number of outcome studies we review suggest that, as with the broader treatment literature for other populations, success (as measured by abstinence) is associated with retention. Retention is facilitated by the provision of support services, such as child care, parenting classes, and vocational training. There is no clear empirical basis for concluding that one type of treatment (for example, residential treatment) is more effective than another.

Back to the future: community involvement in the Healthy Start Program.

This article discusses how community involvement is incorporated into Healthy Start, a major initiative to reduce infant mortality in selected communities with disproportionately high levels of infant mortality. Based on site visits to each of the fifteen original Healthy Start project areas, we discovered that two main community involvement strategies were used: a service consortium model and a community empowerment model. In the service consortium model, the community is involved primarily through a consortium of local providers, other professionals, and some governmental representatives who help to plan services. The community empowerment model involves the community by engaging neighborhood-based groups, contracting with community-based organizations, employing community residents as lay workers in the Healthy Start program, and creating other economic development initiatives. Important lessons drawn from this study are that the purpose and commitment to community involvement is not always clear; that it is difficult to involve community residents; that efforts to involve the community are extremely labor intensive; that given monetary incentives, it is easier to involve community providers than residents; that community involvement may conflict with efficient program operations; that increased community involvement may create program goals that differ from the program's original goals; and that community involvement may slow program development.

Evaluating the Healthy Start program. Design development to evaluative assessment.

The national evaluation of the federally funded Healthy Start program involved translating a design for a process and outcomes evaluation and standard maternal and infant data set, both developed prior to the national evaluation contract award, into an evaluation design and client data collection protocol that could be used to evaluate 15 diverse grantees. This article discusses the experience of creating a process and outcomes evaluation design that was both substantively and methodologically appropriate given such issues as the diversity of grantees and their community-based intervention strategies; the process of accessing secondary data sources, including vital records; the quality of client level data submissions; and the need to incorporate both qualitative and quantitative approaches into the evaluation design. The relevance of this experience for the conduct of other field studies of public health interventions is discussed.

Medicaid managed care encounter data: what, why, and where next?

Managed care now serves 23 percent of the Medicaid population. With the shift to capitation, the fee-for-service (FFS) billing mechanism that has generated much of the administrative data used in policy planning and research no longer exists. This article provides an overview of the types of encounter data currently being required for plans and the problems and issues with providing and analyzing such data. It is based on a review of documentation and interviews with representatives of nine States and the Health Care Financing Administration (HCFA). The article concludes by providing recommendations for HCFA, States, and plans in creating and improving encounter data systems.

International infant mortality rates: bias from reporting differences.

International infant mortality statistics have caused concern in the United States, since the US ranking relative to other developed countries has declined since World War II. This paper suggests that there may be international differences in reporting of very-low-birthweight infants and perinatal deaths and that such reporting differences bias comparisons of national perinatal and infant mortality rates. Efforts must be made to adopt standard conventions for the inclusion of small, early infants and fetal deaths in rate calculations.

Neonatal intensive care and birth weight-specific perinatal mortality in Michigan and Lorraine.

This study investigated the factors influencing use of neonatal intensive care and perinatal mortality in regions of the United States and France, two countries with similar health care systems but different approaches to health financing. The study employed birth certificates from Michigan and a birth registry from Lorraine in 1984. The study showed that geographic access and socioeconomic status were important in determining use of neonatal intensive care in both regions. Socioeconomic factors in perinatal mortality were also shown for both regions, after controlling for gestational age, birth weight, and neonatal intensive care use. In Michigan, infants of mothers with low education had higher mortality rates and in Lorraine residents of low income areas had higher mortality rates. A higher proportion of Michigan women delivered in hospitals with neonatal intensive care than in Lorraine, in all weight/gestation categories. Perinatal mortality rates were also lower in Michigan than in Lorraine, overall and within birth weight categories.

Who is providing ambulatory care to Medicaid beneficiaries with acquired immunodeficiency syndrome in New York State?

This study examined the number of ambulatory care providers treating individuals with the acquired immunodeficiency syndrome who were Medicaid beneficiaries in New York State in 1988 and examined the distribution of this care across various practice settings. The study population was identified retrospectively in the New York State Medical HIV/AIDS Research Data Base and included a cohort of 5535 individuals with the acquired immunodeficiency syndrome who were enrolled in Medicaid in 1988 for at least 6 months after being diagnosed as having the disease and who had at least one ambulatory care encounter during the year. Ambulatory care for the study group was provided by more than 700 hospital or freestanding clinics and more than 3000 private physicians in 1988. Many sites had low caseloads; 47% of the clinics and 68% of the physicians treating this population saw only one or two patients with the acquired immunodeficiency syndrome who were enrolled in Medicaid. More than half the patients in the study group were seen most frequently in clinics for their ambulatory care during 1988. These data provide reassurance that a wide network of providers is involved in the care of patients with the acquired immunodeficiency syndrome who are Medicaid beneficiaries in New York.

Medicaid and pregnancy: issues in expanding eligibility.

Recent federal and state policy has expanded Medicaid eligibility to provide health insurance coverage for pregnant women with family incomes below 133 percent of the federal poverty level. It has yet to be determined how such expanded coverage will affect enrollment in Medicaid or use of prenatal care. Using 1983 data from three states with widely divergent Medicaid programs--including one that already had most of the expanded eligibility options available today--this study found that about 40-60 percent of women who were covered by Medicaid at the time of their deliveries had not been enrolled in the program when they became pregnant. In addition, a large number of women did not receive Medicaid-covered prenatal care early in pregnancy, even though they were enrolled at that time. Almost all women in the study group visited more than one ambulatory care provider at some time during the nine months before birth and one year following birth; 29-51 percent visited more than one hospital outpatient department.

The epidemiology of AIDS in the New York and California Medicaid programs.

An epidemiological analysis of the impact of AIDS on the New York and California Medicaid programs was conducted for 1983-1986. The epidemic affected the New York and California Medicaid programs in several similar ways. The total number of cases grew rapidly over the study time period. In both states, the epidemic was mostly confined to the young adult (21-44 years) age group. Cases were geographically concentrated and highly localized even within counties, but evidence of geographic dispersion to counties outside of the urban centers was also evident. Some dramatic differences were also found between California and New York. Patients with claims histories of drug use were far more likely to be found in the New York population and the proportion of other adult males (our proxy for the homosexual risk group) was higher in California. A much higher proportion of New York's population was female (30 vs. 5%). New York also had many more pediatric cases. Most importantly, New York's raw number of cases was substantially higher than California, with approximately three times as many cases during the time period (1983-1986). There is also substantial evidence that transmission of the disease to heterosexual partners of drug users places heterosexual urban minorities at grave risk of contracting the disease through interaction with infected persons.

The role of community-based organizations in responding to the AIDS epidemic: examples from the HRSA service demonstrations.

This paper considers the role of community-based organizations in providing out-of-hospital services to persons with AIDS, using information collected as part of a case-study evaluation of AIDS service demonstration grants in four cities. Community-based organizations which existed prior to the AIDS epidemic have been reluctant to expand services to persons with AIDS. The widest array of services is provided by new broad-based organizations. Also, exclusive reliance on community-based organizations for service delivery leads to inequities in the delivery system, due to difficulties in developing such organizations in low-income communities.

A comparison of Medicaid and non-Medicaid obstetrical care in California.

The use of prenatal care and rates of low birth weight were examined among four groups of women who delivered in California in October 1983. Medicaid paid for the deliveries of two groups, and two groups were not so covered. The analyses suggest that longer Medicaid enrollment improved the use of prenatal care. The association between prenatal care and birth weight was less clear. For women under Medicaid, measures of infant and maternal morbidity, hospital characteristics, and Medicaid eligibility were all statistically related to charges, payments, and length of stay for the delivery hospitalization.

Prenatal, delivery, and infant care under Medicaid in three states.

Medicaid services and expenditures were analyzed for care during the prenatal, delivery, and post-delivery periods in three States--California, Georgia, and Michigan. Uniform data were used from the Health Care Financing Administration's Medicaid Tape-to-Tape project, 1983-84. Results indicate that from 16 to 24 percent of all births in the States of the study, during the study period, were financed by Medicaid. Overall, the study showed that more than one-half of expenditures for the study population were for the delivery hospitalization, and less than 12 percent were for prenatal care. As expected, a substantial portion of expenditures were for high-cost deliveries, up to 41 percent of total delivery payments. From 33 to 41 percent of total Medicaid expenditures for Aid to Families with Dependent Children were for pregnancy, delivery, and newborn care in 1983.

Patterns of Medicaid utilization and expenditures in selected states: 1980-84.

Data from the Medicaid Tape-to-Tape project are presented for 5 years, 1980-84, and for five States--California, Georgia, Michigan, New York, and Tennessee. These States represent a range of generous to restrictive Medicaid program characteristics. Utilization and expenditure measures are presented for most Medicaid services: hospital services, long-term care, physician services, and prescription drugs. Data are further disaggregated by major eligibility group: children and adults covered by Aid to Families with Dependent Children; aged and disabled covered by Supplemental Security Income. Previous findings of a high degree of Medicaid diversity among States are confirmed here.

Low-income persons' access to health care: NMCUES Medicaid data.

Data from the National Medical Care Utilization and Expenditure Survey (NMCUES) are presented on access to medical care for low-income people in 1980. NMCUES was a national probability household survey jointly sponsored by the National Center for Health Statistics and the Health Care Financing Administration. NMCUES also included four State Medicaid Household Surveys. Data from both the national sample, for all low-income people, and from the four State surveys, for Medicaid people, were included in this analysis. The NMCUES data provided several measures which were previously unavailable on Medicaid experience, in particular, detailed Medicaid eligibility information in combination with income, health status, and health care use. This information can provide a comparison between access to care for those covered by Medicaid, and other low-income persons. In 1980 Medicaid covered a minority of poor and low-income people, only 44 percent of the poor younger than 65 years of age and 38 percent of poor people 65 years of age and older. While almost all elderly had Medicare coverage, about 25 percent of younger low-income people had no form of health insurance, compared with only 9 percent of non poor persons who were uninsured. Another measure of access is a regular source of care, the "place where a person goes for health care when sick." In 1980, 15 percent of people younger than 65 who were covered by Medicaid had no regular source of care. This is similar to the rate for the privately insured. However, the types of providers that were cited as the regular source of care differed. Medicaid recipients were more likely to have hospital outpatient departments and emergency rooms as a regular source.About one-fourth of the uninsured had no regular source of care.The third measure of access presented is physician-visit rates adjusted for health status.Again, Medicaid-covered persons resembled the privately insured, while the uninsured had much lower visit rates, after adjusting for their relatively good health status.Within the Medicaid Program, there are differences between States and eligibility groups in rates of physician visits after adjusting for health status.For example, Texas, the most restrictive of the State Medicaid Programs among the four States surveyed, had substantially lower rates, and those differences were most marked for those covered under the Aid for Dependent Children program population.An examination of trends in measures of access to care during the 1970s suggests that there was little change in access to care for the low-income population during the decade. It is not possible to examine the specific experience of the Medicaid population during the decade owing to a lack of data on that population for the earlier period.

Medicaid Tape-to-Tape findings: California, New York, and Michigan, 1981.

Presented in this report is an overview of Medicaid enrollment, utilization, and expenditures in California during 1981. The California Medicaid program, called Medi-Cal, is the largest in the Nation in terms of program beneficiaries. During 1981, California had one of the most generous Medicaid programs in the country in terms of eligibility and covered services. At the same time, there were benefit limitations and reimbursement restrictions in place that were designed to restrict program expenditures. The data in this report were provided by the State to the Health Care Financing Administration as part of the Medicaid Tape-to-Tape Project. Data from Michigan and New York are also included for comparison purposes.

Longitudinal patterns of enrollment and expenditures for a Medicaid cohort.

This article is based on 4 years of data for a cohort of Medicaid enrollees in California and Georgia to determine patterns of enrollment and expenditures. The analyses were developed from the statistical system known as Tape-to-Tape, which is based on Medicaid enrollment and claims files from these and other States. The composition of the cohort changed over times as a result of the differential rates of turnover for subgroups of the Medicaid population. Longitudinal expenditure patterns also varied by health service and eligibility group. These Medicaid expenditure patterns differed from those observed previously in Medicare studies, undoubtedly reflecting differences in service coverage under Medicare and Medicaid.