MEDICAID

Medicaid



Medicaid

Introduction

A substantial and increasing proportion of women fail to receive adequate prenatal care in the United States, contributing to this country's poor international ranking on infant mortality. Adequate prenatal care has been shown to reduce the risk of poor birth outcomes, especially for women in the highest risk groups, and financial barriers have been a key determinant of insufficient care. Concern about financial access led to federal mandates in the late 1980s to expand eligibility criteria for Medicaid coverage for maternity care. California has utilized federal options and state tobacco tax funds to nearly double the Medi-Cal (California's Medicaid program) income eligibility level for pregnant women. In July 1989, eligibility for coverage of maternity care under Medi-Cal was raised from near the federal poverty level to 185% of the poverty level; on January 1, 1990, eligibility was boosted to 200% of the poverty level.

Medicaid coverage may not confer financial access, however, if a limited number of providers are willing to accept Medicaid obstetric patients. Obstacles to enrolment may delay initiation of care for Medicaid-eligible women regardless of provider availability. Institutional and "personal" barriers, as distinguished from strictly financial issues, have been shown to be powerful predictors of inadequate prenatal care for low-income women. Several studies have shown that Medicaid coverage may not be sufficient to overcome these obstacles.

It is not known to what extent California's Medicaid policies have improved access and thus enhanced prenatal care utilization. This study was conducted to determine whether lack of financing remains an important risk factor for inadequate prenatal care in California and whether coverage by Medi-Cal is associated with timely entry into care and an adequate number of visits once care is initiated. If financing strategies have achieved their maximum benefit, future reforms should focus primarily on nonfinancial access barriers related to the organization and quality of services, logistical problems with transportation and child care, and health knowledge, attitudes, and beliefs. However, the persistence of financial barriers suggests the need for further state and national policy initiatives to expand financial access while addressing other barriers as well.



Discussion

Findings from birth certificates have indicated that maternal racial or ethnic group (African American, Latina, or Native American), age less than 20 years, low educational attainment, high parity, and being unmarried are prominent risk factors for inadequate prenatal care. Although all of these characteristics are correlated with low income and lack of private insurance, birth certificates traditionally have lacked information on financial access. Income is not recorded in US vital statistics, and, prior to 1989, only New York City and the state of Massachusetts included information on insurance in their birth certificate files. Therefore, it generally has not been possible to ascertain the independent role of financial access using vital records data; the only exception in the literature is a study by Cooney using 1981 New York City birth certificates. Studying the utilization of prenatal care by women on Medi-Cal has depended on expensive linkages of vital statistics with Medicaid administrative ...