Welfare and immigration reforms: unintended side effects for Medicaid.

Welfare reform and changes in immigrants' eligibility may lead to significant reductions in Medicaid caseloads, even though many states are expanding Medicaid eligibility rules to accommodate changes under the new welfare programs. In 1996, for the first time in almost a decade, Medicaid participation of adults and children fell about 2 percent, and further reductions seem likely in 1997. The gradual restrictions on new immigrants also will affect future caseloads. Although new initiatives such as the State Children's Health Insurance Program (CHIP) should expand health coverage for children, the welfare reform and immigration changes will disproportionately lead to loss of insurance among adults.

The use of EPSDT and other health care services by children enrolled in Medicaid: the impact of OBRA'89.

To increase the participation of Medicaid children in the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program and to improve their health, Congress included several provisions in the Omnibus Budget Reconciliation Act of 1989 (OBRA'89) that addressed problematic program features. The impact of these provisions on children's health service use was investigated in a study funded by the Health Care Financing Administration. After conducting site visits to four states, the authors analyzed claims data for the children residing there and found evidence that, in 1992, these states placed a higher priority on improving the effectiveness of EPSDT than they did before 1989. The states' efforts to expand the EPSDT provider base and to enhance outreach and service provision were either directly or indirectly inspired by OBRA'89. The authors also found evidence of a significant impact on provider participation and caseloads and on children's use of both preventive care and diagnostic and treatment services. However, the effects were modest in comparison to the size of the progress that is required.

Programs that mitigate the effects of poverty on children.

This article reviews six federally funded in-kind public assistance programs that are intended to mitigate the effects of poverty on low-income children by providing access to basic human necessities such as food, housing, education, and health care. The evidence suggests that, while each program can be improved, these programs do achieve their basic objectives. In general, food stamps, the Special Supplemental Food Program for Women, Infants, and Children (WIC), and school nutrition programs are successful at providing food assistance to low-income children, starting with the prenatal period and continuing through the school years. The Food Stamp Program provides food assistance nationwide to all households solely on the basis of financial need and is central to the food assistance safety net for low-income children. The WIC program has helped reduce the prevalence of iron-deficiency anemia in infants and children and has increased intakes of certain targeted nutrients for program participants. The school nutrition programs provide free or low-cost meals that satisfy the dietary goals of lunches and breakfasts to most school-age children. The Medicaid program has extended health insurance coverage to millions of low-income children. However, many children remain uninsured, and children enrolled in Medicaid do not have the same access to medical care as privately insured children. Relatively little is known about the effects of Medicaid on children's health status. For Head Start, empirical evidence suggests that participating children show enhanced cognitive, social, and physical development in the short term. Studies of the longer-term impacts of Head Start are inconclusive. Although housing assistance improves housing quality and reduces housing costs for recipients, there is a large unmet need for acceptable, affordable housing among poor families. Important gaps remain in our knowledge of the effects of these programs on the well-being of children. Questions regarding a program's effects over time on health and developmental outcomes particularly need more study.

Medicaid coverage of maternity care for aliens in California.

The quantity and cost-effectiveness of prenatal care is a critical reproductive health issue as federal and state legislators consider reducing publicly funded services to aliens. An analysis of data from medi-Cal, California's Medicaid program, shows that undocumented and legalized aliens who qualified for coverage under the provisions of federal legislation or the state's expansion of eligibility criteria accounted for 45% of deliveries financed by Medi-Cal in 1991; outlays for these deliveries are estimated at less than 2% of all Medi-Cal payments for that year. Most of these women also received prenatal care covered by Medi-Cal, but more than half were not enrolled in the program until after the first trimester of pregnancy (and thus may not have received adequate prenatal care). Alien women were enrolled for an average of 5-6 months of their pregnancy, whereas nonalien women who qualified for coverage were enrolled for about seven months. California's Proposition 187 would eliminate funding for prenatal care for undocumented aliens, but public outlays for labor and delivery could grow as a result of an increase in poor birth outcomes.

Chronic estrogen treatment in male rats reveals mammosomatotropes and allows inhibition of prolactin secretion by somatostatin.

Previous in vivo studies demonstrated that estrogen treatment of male rats allows somatostatin (SRIF) to inhibit PRL release. The objective of this study was to determine whether chronic estrogen (E2) treatment of male rats can induce the conversion of somatotropes to mammosomatotropes. In situ hybridization and reverse hemolytic plaque assay were used to evaluate the effects of E2 treatment on GH and PRL messenger RNA (mRNA) content and hormone secretion in individual pituitary cells. Male rats were implanted for 2-6 weeks with placebo or estradiol-containing pellets (5mg/90-day release). Pituitaries were removed and prepared for reverse haemolytic plaque assay to determine PRL and GH secretion. This was followed by in situ hybridization using 35S-labeled riboprobes for PRL and GH mRNA. Chronic E2 treatment increased both the percentage of pituitary cells that secreted PRL and the amount of PRL secreted per cell. Concomitantly, there was a decrease in both the percentage of GH-secreting cells and that amount of GH secreted per cell. In situ hybridization demonstrated that E2 treatment increased PRL mRNA while decreasing GH mRNA in single pituitary cells. Significantly, in control male rat pituitary cell cultures, no PRL-secreting cells were positive for GH mRNA. In contrast, after chronic E2 treatment, 10% of PRL-secreting cells contained GH mRNA. In the control pituitary cell cultures, SRIF had no effect on PRL release, but SRIF significantly inhibited PRL release from pituitary cell cultures prepared from E2-treated male rats. These studies demonstrate that the adult pituitary preserves plasticity and, under the appropriate steroid milieu, allows conversion of somatotropes to mammosomatotropes.

Medicaid and pregnant women: who is being enrolled and when.

Medicaid eligibility expansions and improved enrollment procedures for pregnant women during the late 1980s are examined in this article. Results show that the number of births financed by Medicaid has increased dramatically, and that women are enrolling earlier in the course of pregnancy. Nevertheless, problems continue to exist. If substantial numbers of women continue to enroll late in pregnancy, the expansions may not promote significantly earlier use of prenatal care.

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.

Medicaid eligibility patterns for persons with AIDS in California and New York, 1982-1987.

An analysis of Medicaid eligibility patterns for persons with AIDS (PWAs) was conducted, based on the longitudinal Medicaid eligibility histories of 1,314 AIDS decedents in California and 6,273 AIDS decedents in New York between 1982 and 1987. The study analyzed what eligibility groups or categories and which financial standards PWAs were using to qualify for Medicaid. States have many options with regard to the categories of people they cover under Medicaid and where they set their financial thresholds. The study findings are useful in showing how these policy decisions affect PWAs. A major conclusion of the study is the importance of medically needy coverage for PWAs. Medically needy coverage, which is optional to states, opens up Medicaid to persons of any income level, assuming their medical expenses are high enough. The study also found that PWAs who qualify only through the medically needy provisions have much shorter enrollment and lower lifetime Medicaid expenditures than other PWAs on Medicaid. Presumably, most medically needy only enrollees have other sources of health care coverage in the early stages of the illness. Study data also suggested significant administrative obstacles for PWAs in dealing with the Medicaid eligibility process. Finally, an unexpected study result was that all states may not be aggressively utilizing federal Medicaid financing options for covering the medical assistance expenditures for a significant proportion of the low-income AIDS population.

Deciphering Medicaid data: issues and needs.

The wide range of data bases that can be used for Medicaid analyses and research are reviewed in this article. The Health Care Financing Administration, State Medicaid agencies, and other groups have developed useful data bases and made them available to the public. Efforts could be made to obtain better quality national data, including annual reports on State participation, expenditures and program characteristics, and person-based data bases about medicaid clients and services. State-level analyses and research could be enhanced and disseminated more widely. More complex data collection and analysis efforts are an inevitable tradeoff for the flexibility of the Federal-State structure of Medicaid.

Access to Medicaid and Medicare by the low-income disabled.

The most pervasive eligibility-related problems encountered by low-income disabled persons in gaining access to Medicaid and Medicare are reviewed in this article. A series of options for restructuring program eligibility requirements are presented, with particular attention to improving the plight of the low-income disabled worker during the 24-month waiting period for Medicare. Options for Medicaid involve nationwide income eligibility levels at 100 percent of poverty and mandatory buy-in provisions to Medicaid in all States. For Medicare, the reforms range from altering the waiting period for Medicare by the disabled who are expected to die within 24 months after benefit award to eliminating the waiting period altogether.

Utilization and expenditures under Medicaid for Supplemental Security Income disabled.

Recently available data on major disabling conditions of the Supplemental Security Income disabled are used to examine 1984 patterns of Medicaid expenditures in California, Georgia, Michigan, and Tennessee. Results indicate that 37-58 percent of these expenditures are for enrollees whose major disabling condition involves mental retardation or other mental disorders. This pattern occurs because a high proportion of disabled enrollees have these conditions, rather than high expenses per enrollee. Annual Medicaid expenditures per enrollee were highest for the disabled with neoplasms, blood disorders, and genitourinary conditions. Expenditures per enrollee were higher for younger enrollees and lower for those dually enrolled in Medicare.