Implementation of mandatory Medicaid managed care in Missouri: impacts for pregnant women.

OBJECTIVES: To assess the impact of mandatory Medicaid managed care in Missouri on prenatal care, maternal behavior, and low birth weight among pregnant women enrolled in Medicaid. STUDY DESIGN: Pre-post design using a comparison group with birth certificate and Medicaid enrollment data in 1995 and 2000. METHODS: Pregnant women delivering in 38 counties that implemented managed care in Medicaid were compared preimplementation and postimplementation with pregnant women delivering under Medicaid in 78 counties that remained fee-for-service (FFS) for separate samples of white (37,561) and black (13,640) non-Hispanic women. We calculated difference-in-difference estimates using linear probability regression models that controlled for maternal characteristics and time-invariant county differences. Analyses were stratified based on Medicaid enrollment before and after conception, managed care region, and marital status. RESULTS: Both managed care and FFS counties showed large improvements in prenatal care measures over time for both white and black women. Managed care was associated with a smaller percentage point increase relative to FFS counties in adequate care among whites of 1.9 and among blacks of 8.5, and a larger decrease in smoking of 4.8 and in Women, Infants, and Children Program enrollment of 2.3 among white women. No pattern across managed care regions was found with respect to timing of implementation. Smaller effects were evident among black and single women. CONCLUSIONS: Although women experienced significant improvements statewide in prenatal care under Medicaid, improvements were smaller for managed care counties. Managed care may have a positive impact on smoking cessation, but other policy changes may be needed to improve birth outcomes.

Moving to mandatory Medicaid managed care in Ohio: impacts on pregnant women and infants.

BACKGROUND: Understanding the impacts of Medicaid managed care on pregnant women is critical because Medicaid covers more than a third of all births nationally, many under managed care arrangements. OBJECTIVES: We sought to examine the impacts of mandatory Health Maintenance Organization (HMO) enrollment on prenatal care use, smoking, and birth weight for Medicaid-covered pregnant women in Ohio. RESEARCH DESIGN: Impact estimates are derived from a pre-post design with a comparison group, using Ohio birth certificate data linked to Medicaid enrollment files. Between April 1993 and April 1995 is the baseline period and October 1997 to June 1998 is the post-period. The treatment group consists of deliveries in 6 counties that implemented mandatory HMO enrollment in the mid 1990s; the comparison group consists of deliveries in 4 counties with voluntary HMO enrollment. SUBJECTS: Medicaid-covered deliveries to 24,799 non-Hispanic white women with no college education living in Ohio. MEASURES: Seven outcomes are analyzed: first trimester care; last trimester or no care; adequate prenatal care; inadequate prenatal care; smoking during pregnancy; and birth weight. RESULTS: Our findings indicate that mandatory HMO enrollment in Ohio's Medicaid program had positive effects on prenatal care and led to reductions in maternal smoking. No effects were found on birth weight. CONCLUSIONS: Even with the improvements related to Medicaid managed care, rates of inadequate prenatal care and maternal smoking remain relatively high. Addressing the underlying risk factors that are facing poor women and further expanding public programs may be critical to achieving further progress.