Medicaid Expansions and Welfare Contractions: Offsetting Effects on Prenatal Care and Infant Health?

Evaluations of changes to the Medicaid program have focused on increases in the generosity of income cutoffs for eligibility. Previous research shows that despite dramatic increases in the number of births paid for by Medicaid, many eligible women are still getting inadequate prenatal care. States have addressed this problem by adopting administrative measures designed to simplify the Medicaid application process and encourage the use of prenatal care. At the same time, recent declines in welfare caseloads may have caused many women to lose their Medicaid coverage by effectively increasing administrative barriers to obtaining care. We examine the effects of changes in income eligibility, administrative reforms, and welfare caseloads on the use of prenatal care and infant health using data from birth certificates covering all U.S. births between 1990 and 1996. We find that increases in income cutoffs were associated with increased use of prenatal care among whites, while decreases in welfare caseloads were associated with reduced use of prenatal care, especially among blacks. Reduced form estimates suggest that changes in income cutoffs were associated with a reduced probability of fetal death among blacks and disadvantaged whites. None of the administrative reforms we consider had consistently positive effects. These results suggest that the administrative reforms undertaken to date have been insufficient to break the close link between participation in welfare and access to prenatal care under the Medicaid program