Dissertation
Effects of the ACA Medicaid expansions and Medicaid accountable care organizations on children’s outcomes
University of Iowa
Doctor of Philosophy (PhD), University of Iowa
Summer 2023
DOI: 10.25820/etd.006871
Abstract
IntroductionThe United States (U.S.) lags behind other industrialized countries on various population health indicators, specifically those related to children, despite the country’s greater health expenditures per capita. Racial/ethnic disparities in early childhood health such as the rates of low birthweight, preterm birth, and infant mortality are also substantial. These differences in infant health carry forward and contribute to disparities in health and well-being later in childhood. Medicaid is a public health insurance mutually financed by the federal and state governments, but operated and regulated by states following federal stipulations. Over the past few decades, significant variations affected the Medicaid program and health care industry, with policy reforms involving both expanding eligibility and changing healthcare delivery systems. The Affordable Care Act (ACA) Medicaid expansions extended coverage to adults with a household income up to 138% of the Federal Poverty Level, regardless of pregnancy status. The ACA also included provisions enabling the establishment and growth of Accountable Care Organizations (ACOs) within Medicare, which influenced the development of Medicaid ACOs.
ObjectiveThis dissertation has a three-fold objective: 1) to examine year-by-year effects of the ACA Medicaid expansions on infant mortality by race and ethnicity over the first six years after the 2014 expansions; 2) to identify the year-by-year effects of the ACA Medicaid expansions on birth outcomes of non-Hispanic Black and non-Hispanic White women over the first seven years after the 2014 expansions, while examining year-by-year changes in prenatal care use and maternal smoking; and 3) to evaluate the effects of the implementation of Medicaid ACOs on children’s access to and utilization of health care services.
MethodsData come from 1) the publicly available Multiple Cause of Death 2011‒2019 data files from the National Center for Health Statistics (NCHS); 2) the restricted access individual-level birth certificates for years 2011 through 2020 from the NCHS; and 3) the publicly available National Survey of Children’s Health covering the period between 2016 and 2021. This dissertation employs quasi-experimental designs involving classical and event-study difference-in-differences approaches, and a two-way fixed effects model.
ResultsThis work sheds light on improvements in early child health and mortality outcomes associated with the ACA Medicaid expansions. These expansions are specifically associated with declines in overall infant mortality rate in 2019, Black infants’ mortality in 2018 and 2019, and Hispanic infants’ mortality in 2015–2019. The expansions are also associated with a reduction in the rate of low birthweight among non-Hispanic Black women although this effect seems to be concentrated among the married sub-group. The evidence further shows a decrease in maternal smoking among the married non-Hispanic Black women. Moreover, while there is no evidence of a regular, straightforward pattern of an effect of Medicaid ACOs on children’s access to and utilization of health services, some outcomes direct the audience’s attention to tangible changes nationwide and by groups of states.
Policy ImplicationsFindings from this dissertation put forward for consideration promising long-run impacts of preconception health insurance coverage among low-income women of childbearing age. The heterogeneity in effects raises the question as to how behavioral responses to health insurance eligibility and take-up of Medicaid differ. While expanding income eligibility to extend coverage opportunities to a larger group of vulnerable population is necessary to address financial barriers to health care, it remains insufficient to tackle sub-optimal insurance take-up, or subsequent access to and utilization of health services that are exacerbated by non-insurance hurdles. There is no one-size-fits-all solution; diversified interventions targeted towards potential differences in behavioral responses to eligibility, insurance take-up, and access to and utilization of health services could help address gaps in improvements across groups.
Future Research DirectionsFuture research can build on these results by making use of the restricted, individual-level, linked natality/mortality data to focus on infants directly affected by the ACA Medicaid expansions. Researchers can also leverage the universe of Medicaid claims data that would not only have more accurate outcome measures for children, but also a broader range of comprehensive variables. It would also be worthwhile for future research to evaluate conceptually relevant mechanisms including but not limited to preconception care, such as maternal health, coverage, access to and utilization of health services outside of the pregnancy period as theory suggests that these pathways potentially affect early child health, whether birth outcomes or infant mortality rates. Furthermore, while leveraging existing data sources would be valuable, investing efforts and resources to systematically collect data on Medicaid ACOs is fundamental to set the infrastructure for future robust Medicaid ACO research nationwide. This is particularly important with the sizable diversity in health care delivery among Medicaid ACOs, which would shed light on important factors and elements contributing to differences between high- and low-performing Medicaid ACOs.
Details
- Title: Subtitle
- Effects of the ACA Medicaid expansions and Medicaid accountable care organizations on children’s outcomes
- Creators
- Joanne Constantine
- Contributors
- George Labib Wehby (Advisor)Kanika Arora (Committee Member)Keith J Mueller (Committee Member)Hari P Sharma (Committee Member)
- Resource Type
- Dissertation
- Degree Awarded
- Doctor of Philosophy (PhD), University of Iowa
- Degree in
- Health Management and Policy
- Date degree season
- Summer 2023
- DOI
- 10.25820/etd.006871
- Publisher
- University of Iowa
- Number of pages
- xix, 231 pages
- Copyright
- Copyright 2023 Joanne Constantine
- Language
- English
- Date submitted
- 07/17/2023
- Description illustrations
- illustrations
- Description bibliographic
- Includes bibliographical references (pages 100-118).
- Public Abstract (ETD)
The United States ranks below industrialized countries on key children’s indicators. Substantial racial/ethnic differences also exist in early childhood health such as rates of low birthweight (LBW), preterm birth, and infant mortality, which contribute to later childhood disparities. Medicaid policy reforms expanded eligibility and changed delivery systems.
This dissertation evaluates causal effects of Medicaid expansions under the Affordable Care Act (ACA) on infant mortality by race and ethnicity, and on birth outcomes of non-Hispanic Black (NHB) and non-Hispanic White (NHW) women. Furthermore, it causally examines effects of Medicaid Accountable Care Organizations (ACOs) on children’s access to and utilization of health services.
The ACA Medicaid expansions are associated with declines in overall infant mortality rate in 2019, Black infants’ mortality in 2018 and 2019, and Hispanic infants’ mortality in 2015–2019. The expansions are also associated with a reduction in the rate of LBW among NHB women, although this effect is concentrated among the married. Moreover, while there is no evidence of a consistent effect of Medicaid ACOs on children’s health care access and use, some outcomes reflect concrete changes nationwide and by groups of states.
There are promising long-run impacts of preconception health insurance among low-income women of childbearing age. Heterogeneous effects raise the question as to how behavioral responses to insurance eligibility and take-up differ. Expanding income eligibility is necessary to address financial barriers to care but insufficient to tackle sub-optimal insurance take-up, or subsequent health care access and utilization. Diversified interventions could address gaps in improvements across groups.
- Academic Unit
- Health Management and Policy
- Record Identifier
- 9984454540902771
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