Is Medicaid pronatalist? The effect of eligibility expansions on abortions and births. (ARTICLES).(Statistical Data Included)

Context: Income thresholds for Medicaid eligibility for pregnant women were raised in two phases between 1987 and 1991. During roughly the same period, the U.S. fertility rate rose and the abortion rate declined; changes were particularly marked among young women, raising the possibility that fertility increases were related to Medicaid expansions.

Methods: Pooled time-series cross-section regressions were used to examine the effects of the Medicaid eligibility expansions in 15 states on rates of abortions and births among unmarried women aged 19-27 with 12 or fewer years of schooling. Abortion data came from the National Center for Health Statistics or state health departments and were aggregated by women's age, race, marital status and schooling; data on births were from national natality tapes.

Results: The Medicaid expansions were associated with a 5% increase in the birthrate among white women, but did not influence the rate among black women. Overall, no effect on the abortion rate was evident, but in analyses restricted to a subsample of eight states with the most complete abortion data, the rate among white women showed a significant decline after the second phase of expansions.

Conclusions: Subsidized health care for low-income pregnant women in these 15 states may have encouraged white women to have more children than they would have without coverage.

Through the mid-1980s, Medicaid eligibility requirements included very low income thresholds established by the individual states. Between 1987 and 1991, eligibility standards for poor and near-poor pregnant women were expanded dramatically. The 1986 Omnibus Budget and Reconciliation Act (OBRA) permitted states to extend eligibility (and receive reimbursement for services provided) to individuals with an income up to 100% of the federal poverty level. The 1987 OBRA permitted states to raise the threshold to 185% of the poverty level, and the 1989 OBRA mandated increases to 133% of poverty. (1) As a result, the proportion of births financed by Medicaid rose from 15% in 1985 to 32% in 19912 and to 39% in 1994. (3) Furthermore, the number of children enrolled in Medicaid increased by 47% between 1989 and 1992. (4)

Coincident with these eligibility expansions, the U.S. fertility rate rose by 7%, from a recent trough of 65.4 births per 1,000 women aged 15-44 in 1986 to 69.6 per 1,000 in 1991. Over roughly the same period, the abortion rate fell from 28.0 abortions per 1,000 women aged 15-44 in 1985 to 25.9 per 1,000 in 1992. (5) Among subgroups, changes were more dramatic. The fertility rate of unmarried women aged 20-24 rose from 46.5 to 68.0 births per 1,000 between 1985 and 1991, (6) and the abortion rate for teenagers fell from 43.5 to 37.7 per 1,000 over the same period. (7)

In this article, we examine trends in the rates of births and abortions between 1986 and 1992, and investigate whether changes were related to increases in Medicaid eligibility thresholds for pregnant women. Specifically, we examine variations in the timing and magnitude of state expansions in Medicaid eligibility to assess whether publicly provided health insurance for pregnancy, delivery and postpartum care was associated with changes in rates of births and abortions in 15 states.