Advertisement

Medicaid Covered Births, 2008 Through 2010, in the Context of the Implementation of Health Reform

      Abstract

      Background

      Medicaid is a major source of public health care financing for pregnant women and deliveries in the United States. Starting in 2014, some states will extend Medicaid to thousands of previously uninsured, low-income women. Given this changing landscape, it is important to have a baseline of current levels of Medicaid financing for births in each state. This article aims to 1) provide up-to-date, multiyear data for all states, the District of Columbia, and Puerto Rico and 2) summarize issues of data comparability in view of increased interest in program performance and impact assessment.

      Methods

      We collected 2008–2010 data on Medicaid births from individual state contacts during the winter of 2012–2013, systematically documenting sources and challenges.

      Findings

      In 2010, Medicaid financed 48% of all births, an increase of 19% in the proportion of all births covered by Medicaid in 2008. Percentages varied among states. Numerous data challenges were found.

      Conclusions/Implications for Research and Policy

      Consistent adoption of the 2003 birth certificate in all states would allow the National Center for Health Statistics Natality Detail dataset to serve as a nationally representative source of data for the financing of births in the United States. As states expand coverage to low-income women, women of childbearing age will be able to obtain coverage before and between pregnancies, allowing for access to services that could improve their overall and reproductive health, as well as birth outcomes. Improved birth outcomes could translate into substantial cost savings, because the costs associated with preterm births are estimated to be 10 times greater than those for full-term births.

      Introduction and Background

      The Medicaid program is a major source of public financing for health care services provided to pregnant women, infants, and children in the United States. In 2012, the program covered 35% of all children, including infants, as well as a significant number of deliveries across the nation (
      Kaiser Commission on Medicaid and the Uninsured
      Medicaid: A primer.
      ). Hospital discharge data analyzed for the Agency for Healthcare Research and Quality indicate that Medicaid paid for 44.4% of complicated deliveries and 56.3% of noncomplicated deliveries nationally in 2009 (
      • Stranges E.
      • Wier L.
      • Elixhauser A.
      Complicating conditions of vaginal deliveries and cesarean sections, 2009. HCUP Statistical Brief #131.
      ). According to the Guttmacher Institute, 47.6% of all 4.2 million births in 2006, intended or unintended, were publicly funded (
      • Sonfield A.
      • Kost K.
      • Benson Gold R.
      • Finer L.
      The public costs of births resulting from unintended pregnancies: National and state-level estimates.
      ). Yet another estimate from the National Governors' Association (NGA) puts Medicaid-funded births at nearly half of all births in 2010, up from 41% in 2003 (

      National Governors’ Association (NGA). (2011). 2010 Maternal and child health update: States makes progress towards improving systems of care. Retrieved from http://www.nga.org/files/live/sites/NGA/files/pdf/MCHUPDATE2010.PDF.

      ).
      The majority of women enrolled in Medicaid (72%) are in their reproductive years (ages 18–44) and qualify on the basis of 1) income and/or 2) pregnancy, disability, or by the virtue of being a working or nonworking parent (

      Kaiser Family Foundation. (2012). Medicaid’s role for women across the lifespan: Current issues and the impact of the Affordable Care Act. Women’s issue brief. Washington, DC: Author.

      ). Under federal law, states participating in the Medicaid program are required to cover pregnant women, infants, and young children ages 0 to 5 under 133% of the federal poverty level (FPL) and school-aged children ages 6 to 18 under 100% FPL. Many states have expanded Medicaid eligibility above these thresholds for particular groups of women and children. For example, as of January 2012, 39 states had expanded Medicaid eligibility for pregnant women to 185% FPL and beyond (

      Kaiser Commission on Medicaid and the Uninsured. (2012), Where are states today: Medicaid and CHIP eligibility levels for children and non-disabled adults. Retrieved from http://www.kff.org/medicaid/upload/7993-02.pdf.

      ).
      Although states offer Medicaid coverage to working and nonworking women who are parents and women who have disabilities, the income eligibility levels are generally very low (i.e., far below the FPL), thereby excluding many poor women from coverage, such that only 10% of all women are covered by Medicaid (

      Kaiser Family Foundation. (2011). Women’s Health Care Chartbook: Key Findings from Kaiser Women’s Health Survey. Washington, DC: Author.

      ). In addition, only eight states and the District of Columbia provide coverage for some adults, including women of reproductive age, who do not have children (but could become pregnant;
      • Heberlein M.
      • Brooks T.
      • Alker J.
      • Artiga S.
      • Stephens J.
      Getting into gear for 2014: Findings from a 50-state survey of eligibility, enrollment, renewal, and cost-sharing policies in Medicaid and CHIP, 2012–2013.
      ). In 2009, more than one in five women of reproductive age was uninsured, representing approximately 13.8 million women ages 15 to 44 ().
      The Affordable Care Act (ACA) will extend Medicaid coverage to thousands of low-income women, previously uninsured, some of whom will become pregnant.
      • Kenney G.
      • Zuckerman S.
      • Dubay L.
      • Huntress M.
      • Lynch V.
      • Haley J.
      • et al.
      Opting in to the Medicaid expansion under ACA: Who are the uninsured who could gain health insurance coverage. Timely analysis of immediate health policy issues.
      estimate that 4.6 million currently uninsured women ages 19 to 44 could qualify for Medicaid coverage if all states chose to expand eligibility to 133% of the FPL (or 138% owing to a 5% income disregard). However, the Supreme Court decision issued in June 2012 leaves Medicaid expansion under ACA uncertain, because expansion is now optional and left to states to decide. Further, it is likely that many women will remain uninsured because women at the lowest income levels do not qualify for the Advance Premium Tax Credit available to others through the health exchange plans (

      Pellegrini, C., & Garro, N. (2013). Medicaid expansion: Benefits for women of childbearing age and their children. Retrieved from: http://healthaffairs.org/blog/2013/02/22/medicaid-expansion-benefits-for-women-of-childbearing-age-and-their-children/.

      ). Research shows that adults with family incomes up to 133% FPL are more likely to experience disruption in eligibility, which would likely lead to churning between programs more than once within a year for women (
      • Sommers B.
      • Rosenbaum S.
      Issues in health reform: How changes in eligibility may move millions back and forth between Medicaid and insurance exchanges.
      ).
      As part of ACA, states need to maintain their Medicaid eligibility levels for adults until health insurance exchanges are fully operational, presumably until January 1, 2014 (
      • Sommers B.
      • Rosenbaum S.
      Issues in health reform: How changes in eligibility may move millions back and forth between Medicaid and insurance exchanges.
      ). State maintenance of effort requirements do not apply to adults without disabilities or who are not pregnant if their income is above 133% FPL and the state can prove current or projected budget deficits (
      • Sommers B.
      • Rosenbaum S.
      Issues in health reform: How changes in eligibility may move millions back and forth between Medicaid and insurance exchanges.
      ). Hence, some women may lose their Medicaid coverage while others will remain uninsured, either because they are eligible but not currently enrolled in Medicaid or owing to restrictions based on their immigration status. For all of these women, emergency Medicaid will remain an important source of financing for births.
      Given this changing landscape, it is important to have a baseline understanding of current levels of Medicaid financing for births in the states. Information on the percentage of births covered by Medicaid nationally and by each state is scarce and often inconsistent, as indicated. The two most recent studies to date on Medicaid-financed births by state were published by the NGA in 2011, using its own survey of all 50 states and the five U.S. territories fielded in August 2010 and completed in fall (

      National Governors Association (NGA). (2010). Maternal and child health update: States make progress towards improving systems of care. Issue Brief [see Table 6]. Retrieved from: http://www.nga.org/files/live/sites/NGA/files/pdf/MCHUPDATE2010.PDF.

      ), and the Guttmacher Institute in 2011, using 2006 Pregnancy Risk Assessment Monitoring System (PRAMS) data and other sources for all 50 states and the District of Columbia (

      National Governors Association (NGA). (2010). Maternal and child health update: States make progress towards improving systems of care. Issue Brief [see Table 6]. Retrieved from: http://www.nga.org/files/live/sites/NGA/files/pdf/MCHUPDATE2010.PDF.

      ,
      • Sonfield A.
      • Kost K.
      • Benson Gold R.
      • Finer L.
      The public costs of births resulting from unintended pregnancies: National and state-level estimates.
      ). The NGA gathers data from U.S. states and territories through its Annual Maternal and Child Health Survey of Governors. Although the NGA provides a rough estimate of the total U.S. births funded by Medicaid, its most recent reports indicate missing or incomplete data for 20 states and it is unclear how the data included in the report were collected and defined (

      National Governors’ Association (NGA). (2011). 2010 Maternal and child health update: States makes progress towards improving systems of care. Retrieved from http://www.nga.org/files/live/sites/NGA/files/pdf/MCHUPDATE2010.PDF.

      ). The Guttmacher Institute analyzed PRAMS data from 2006 but has not updated these data since. PRAMS is a state-specific, population-based surveillance system sponsored by the U.S. Centers for Disease Control and Prevention, which identifies and monitors select maternal experiences before, during, and after pregnancy. Not all states participate in PRAMS and participation is not consistent from year to year. States survey by mail and telephone residents who have recently given birth.
      The most comprehensive source for U.S. birth data by payer is the 2010 Natality Detail dataset, compiled by the U.S. Centers for Disease Control and Prevention's National Center for Health Statistics (NCHS). The Natality Detail dataset is an annual census of live births based on the U.S. Standard Certificate of Live Birth. The 2010 Natality data include birth data based on two birth certificate formats, the 1989 version and the 2003 revision of the U.S. Standard Certificate of Live Birth. Only states using the 2003 birth certificate format reported “principal source of payment for this delivery” (

      U.S. Centers for Disease Control and Prevention. (2010). User guide to the 2010 Natality Public Use File [data file]. Retrieved from ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataet_Documentation/DVS/natality/UserGuide2010.pdf.

      ). As of January 1, 2010, 33 states, the District of Columbia, and two territories had implemented the revised birth certificates, representing 76% of all 2010 U.S. births (

      U.S. Centers for Disease Control and Prevention. (2010). User guide to the 2010 Natality Public Use File [data file]. Retrieved from ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataet_Documentation/DVS/natality/UserGuide2010.pdf.

      ). Thus, although most comprehensive, the Natality Detail dataset excludes data from a significant number of states (n = 17). In addition, whereas the 2010 version represents the first public release of this type of data by payer, the delayed release of the 2010 Natality Detail data reduced the time available to analyze the data before Medicaid eligibility changes taking effect across the nation.
      With this time constraint in mind, this paper seeks to fulfill the following two aims: 1) To provide up-to-date, multiyear data for all states, the District of Columbia and Puerto Rico for Medicaid-funded births as a baseline pre-ACA eligibility changes; and 2) to summarize issues of data comparability in light of increased requirements on states and interest from policymakers in assessing program performance and impact.

      Methods

      In an effort to update the available information on Medicaid-funded births and supplement the NCHS payer data anticipated for release in 2013, we collected 2008–2010 data on Medicaid births from individual state contacts during the winter of 2012–2013. Our priority with the individual state data collection was to gather birth frequencies for the 17 states that have not adopted the 2003 birth certificate, because their Medicaid births are not reflected in the NCHS dataset, although we were able to collect data from all 50 states, Washington DC, and Puerto Rico. Throughout the process, we noted inconsistencies in the way states gather and report Medicaid birth data. For some states, the frequencies were obtained from Vital Statistics, whereas others provided data using Medicaid data systems or state hospital discharge datasets.
      The NCHS Natality Detail dataset provided a baseline for total birth counts for all states for 2008 through 2010. State Vital Statistics units' websites were scanned for total birth counts and Medicaid birth frequencies in October and November 2012. Several states (AL, AR, NH, OR, PA, SD, WY) had published births by payer online and for those states the state website was the primary source of information with follow-up calls for clarification as needed. We then proceeded to contact representatives from state Vital Statistics units to collect total birth and Medicaid birth frequencies for the remaining states in November and December of 2012.
      Based on the 2010 NCHS Natality file, 33 states and the District of Columbia utilize the 2003 certificate containing payer information (

      U.S. Centers for Disease Control and Prevention. (2010). User guide to the 2010 Natality Public Use File [data file]. Retrieved from ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataet_Documentation/DVS/natality/UserGuide2010.pdf.

      ). However, we collected information from Vital Statistics units for 41 states and the District of Columbia, 30 of them being states with new certificates and 11 of the 17 states without revised birth certificates who have added their own payer question. In some of the states (IL, NM, OK, TX) and the District of Columbia with payer source information in their birth certificates, we chose to utilize data from a different source (i.e., Medicaid claims data or hospital discharge data) owing to poor data quality and a large number of records with missing payer information.
      Medicaid birth frequencies were collected from Medicaid data systems for 5 of the 17 states and Puerto Rico that do not use the revised birth certificate and Hawaii provided data from its hospital discharge database. Wherever possible, we used Medicaid claims data over hospital discharge data for consistency. However, the choice of data source depended on the individual state reporting systems and preferences of the state contacts about the most convenient way to generate the data. Data sources for Medicaid-funded births are reported by state and territory in Table 1.
      Table 1Data Sources for Medicaid-Funded Births by State
      StateRevised Birth CertificateSource of Birth Data
      AlabamaNoVital Records
      AlaskaNoVital Records and Medicaid
      ArizonaNoVital Records
      ArkansasNoMedicaid
      CaliforniaYesVital Records
      ColoradoYesVital Records
      ConnecticutNoVital Records and Medicaid
      DelawareYesVital Records
      District of ColumbiaYesMedicaid
      FloridaYesVital Records
      GeorgiaYesVital Records
      HawaiiNoHCUP
      IdahoYesVital Records
      IllinoisYesMedicaid
      IndianaYesVital Records
      IowaYesVital Records and Medicaid
      KansasYesVital Records
      KentuckyYesVital Records
      LouisianaNoMedicaid
      MaineNoMedicaid
      MarylandYesVital Records
      MassachusettsNoVital Records
      MichiganYesVital Records
      MinnesotaNoVital Records and Medicaid
      MississippiNoMedicaid
      MissouriYesVital Records
      MontanaYesVital Records
      NebraskaYesVital Records
      NevadaYesMedicaid
      New HampshireYesVital Records
      New JerseyNoVital Records
      New MexicoYesHCUP
      New YorkYesVital Records
      North CarolinaNoVital Records and Medicaid
      North DakotaYesVital Records
      OhioYesVital Records
      OklahomaYesMedicaid
      OregonYesVital Records
      PennsylvaniaYesVital Records
      Puerto RicoNoMedicaid
      Rhode IslandNoVital Records
      South CarolinaYesVital Records
      South DakotaYesVital Records
      TennesseeYesVital Records
      TexasYesHCUP
      UtahYesVital Records
      VermontYesVital Records
      VirginiaNoVital Records
      WashingtonYesVital Records
      West VirginiaNoVital Records
      WisconsinNoVital Records and Medicaid
      WyomingYesVital Records
      Abbreviation: HCUP, Healthcare Cost and Utilization Project.

      Results

       State-Based Medicaid Birth Estimates

      In 2010, Medicaid financed approximately 48% of births in the United States. The proportion of births financed by Medicaid varied substantially among states, with fewer than one quarter of births financed by Medicaid in Hawaii (24%) and nearly 70% financed by Medicaid in Louisiana (Table 2).
      Table 2Births Financed by Medicaid, 2008 to 2010
      Missing data are not included in the total national estimates.
      State2008 Total Births2008 Medicaid Births2008 % Medicaid Births2009 Total Births2009 Medicaid Births2009 % Medicaid Births2010 Total Births2010 Medicaid Births2010 % Medicaid Births
      Alabama64,34531,10648.3462,47630,98049.5959,97931,49852.52
      Alaska11,4695,74350.0711,3425,91652.1611,5026,05352.63
      Arizona99,21552,08152.4992,61649,53853.4987,05346,39353.29
      Arkansas
      AR reported the number of newborns on Medicaid as opposed to birth counts.
      40,66225,92863.7639,68625,33763.8438,22425,65967.13
      California551,567260,19547.17526,774248,70547.21509,797242,73247.60
      Colorado70,02924,00734.2868,60724,91136.3166,34924,43136.82
      Connecticut40,38811,39328.2138,87611,70030.1037,44811,77031.43
      Delaware
      DE does not have final figures for 2010 and is waiting on information from one of the payers.
      12,0165,74047.7711,3695,52948.63
      District of Columbia
      The District of Columbia did not provide Medicaid claims data for 2008 owing to data quality issues.
      ,
      Some of the states (MD, MS, NC, OK, UT) and the District of Columbia adopted the 2003 certificate in the middle of our data collection period, either in 2009 or 2010, thus producing inconsistencies in the data within a state over time as the questions changed.
      9,1349,0086,44671.569,1566,21867.91
      Florida231,417102,33944.22221,391105,25747.54214,519104,72148.82
      Georgia146,41455,05337.60141,33257,41640.62133,66856,00941.90
      Hawaii19,4624,45922.9118,8914,70724.9218,9334,55124.04
      Idaho25,1568,15532.4223,7268,74436.8523,2028,95438.59
      Illinois176,63489,80050.84171,07788,72251.86165,20085,97852.04
      Indiana88,67938,84243.8086,12639,27045.6083,86739,07146.59
      Iowa40,22115,29738.0339,66215,73239.6738,51415,58240.46
      Kansas41,81510,68925.5641,38811,22527.1240,43913,15932.54
      Kentucky56,90125,75645.2655,92924,58443.9654,12823,59443.59
      Louisiana65,06345,33969.6865,10945,07669.2362,55543,17569.02
      Maine13,605683350.2213,466710352.7512,950816463.04
      Maryland
      Some of the states (MD, MS, NC, OK, UT) and the District of Columbia adopted the 2003 certificate in the middle of our data collection period, either in 2009 or 2010, thus producing inconsistencies in the data within a state over time as the questions changed.
      77,26845,01958.2674,99943,28157.7173,78319,13225.93
      Massachusetts76,96919,46925.2974,96619,66626.2372,83519,48526.75
      Michigan121,23152,22643.08117,30951,62044.00114,71751,94445.28
      Minnesota72,38227,89738.5470,61730,52143.2268,40729,98343.83
      Mississippi
      Some of the states (MD, MS, NC, OK, UT) and the District of Columbia adopted the 2003 certificate in the middle of our data collection period, either in 2009 or 2010, thus producing inconsistencies in the data within a state over time as the questions changed.
      44,90427,99462.3442,80927,60064.4739,98425,86464.69
      Missouri80,94438,00446.9578,84937,67547.7876,71832,41142.25
      Montana12,5953,79530.1312,2803,98532.4512,0584,22535.04
      Nebraska26,99210,04937.2326,93110,03837.2725,9168,07031.14
      Nevada39,47414,80137.5037,52314,44638.5035,72415,73744.05
      New Hampshire13,6843,83928.0513,3893,86528.8712,8733,84529.87
      New Jersey112,42826,90423.93109,54326,74824.42101,40928,49928.10
      New Mexico30,15616,51854.7828,87316,03455.5327,79514,83253.36
      New York249,655111,28244.57246,592112,81445.75242,914111,14445.75
      North Carolina
      Some of the states (MD, MS, NC, OK, UT) and the District of Columbia adopted the 2003 certificate in the middle of our data collection period, either in 2009 or 2010, thus producing inconsistencies in the data within a state over time as the questions changed.
      130,75868,83852.65126,78568,18653.78122,30265,77553.78
      North Dakota8,9312,53928.438,9742,56228.559,0882,59428.54
      Ohio148,59255,85937.59144,56955,95738.71139,03453,14038.22
      Oklahoma
      Some of the states (MD, MS, NC, OK, UT) and the District of Columbia adopted the 2003 certificate in the middle of our data collection period, either in 2009 or 2010, thus producing inconsistencies in the data within a state over time as the questions changed.
      53,73332,60160.6752,72933,89864.2951,79833,12563.95
      Oregon49,11719,99340.7047,18819,86542.1045,59620,46344.88
      Pennsylvania139,83043,64231.21139,65346,03432.96138,53245,26032.67
      Puerto Rico45,68925,61356.0644,83026,79959.7842,20325,23159.78
      Rhode Island12,0315,49545.6711,4215,32146.5911,1665,14246.05
      South Carolina63,07730,34148.1060,68228,34846.7258,32529,15349.98
      South Dakota12,0744,09633.9211,9304,22535.4111,7954,24435.98
      Tennessee85,48041,78448.8882,10941,41350.4479,34540,70351.30
      Texas412,224181,30543.98408,487191,51346.88392,876187,14047.63
      Utah
      Some of the states (MD, MS, NC, OK, UT) and the District of Columbia adopted the 2003 certificate in the middle of our data collection period, either in 2009 or 2010, thus producing inconsistencies in the data within a state over time as the questions changed.
      ,
      UT provided resident data in state only.
      55,37213,79624.9253,58715,62829.1651,92515,91130.64
      Vermont6,3422,80544.236,1092,79145.696,2242,90146.61
      Virginia106,57828,18926.45104,97928,04726.72102,93430,62629.75
      Washington90,27033,68737.3289,24234,80239.0086,48033,54538.79
      West Virginia21,4939,23242.9521,2759,46444.4820,40710,57551.82
      Wisconsin68,36733,84849.5170,82434,69448.9968,36733,84849.51
      Wyoming8,0222,94436.707,8742,89636.787,5412,89238.35
      Total4,280,8541,715,95740.083,942,9721,730,56843.893,780,5191,805,15147.75
      Missing data are not included in the total national estimates.
      AR reported the number of newborns on Medicaid as opposed to birth counts.
      DE does not have final figures for 2010 and is waiting on information from one of the payers.
      § The District of Columbia did not provide Medicaid claims data for 2008 owing to data quality issues.
      Some of the states (MD, MS, NC, OK, UT) and the District of Columbia adopted the 2003 certificate in the middle of our data collection period, either in 2009 or 2010, thus producing inconsistencies in the data within a state over time as the questions changed.
      UT provided resident data in state only.
      Overall, northeastern and northwestern states in the United States tend to have the lowest proportion of births financed by Medicaid, whereas southern states tend to have the highest proportions of Medicaid-financed births (Figure 1). Arkansas, Louisiana, Maine, Mississippi, the District of Columbia, and Puerto Rico each reported over 60% of births financed by Medicaid in 2010.
      Figure thumbnail gr1
      Figure 1Percent of births financed by Medicaid (2010).
      The proportion of births financed by Medicaid has increased over the last few years. The 2010 estimate for proportion of births financed by Medicaid represents a 9% increase in the proportion of births financed by Medicaid from the prior year, when Medicaid covered 44% of births, and a 19% increase from 2008 when Medicaid covered 40% of births. The percent change in Medicaid-funded births varies among the states, with some seeing declines in the proportion of Medicaid births over the past few years, whereas others have seen increases in Medicaid-financed births (Table 3).
      Table 3Percent Change in Number of Births Financed by Medicaid, 2008 to 2010
      State% Change 2008–2009% Change 2009–2010% Change 2008–2010
      Alabama2.595.918.65
      Alaska4.170.905.11
      Arizona1.91−0.371.52
      Arkansas0.135.155.29
      California0.080.830.91
      Colorado5.921.407.41
      Connecticut6.704.4211.41
      Delaware1.80
      District of Columbia−5.10
      Florida7.512.6910.40
      Georgia8.033.1511.44
      Hawaii8.77−3.534.93
      Idaho13.664.7219.03
      Illinois2.010.352.37
      Indiana4.112.176.37
      Iowa4.311.996.39
      Kansas6.1019.9927.31
      Kentucky−2.87−0.84−3.69
      Louisiana−0.65−0.30−0.95
      Maine5.0419.5125.53
      Maryland−0.94−55.07−55.49
      Massachusetts3.721.995.78
      Michigan2.142.915.11
      Minnesota12.141.4113.73
      Mississippi3.420.343.77
      Missouri1.77−11.57−10.01
      Montana7.707.9816.30
      Nebraska0.11−16.45−16.36
      Nevada2.6715.5017.47
      New Hampshire2.923.466.49
      New Jersey2.0515.0717.43
      New Mexico1.37−3.91−2.59
      New York2.650.002.65
      North Carolina2.150.002.15
      North Dakota0.42−0.040.39
      Ohio2.98−1.271.68
      Oklahoma5.97−0.535.41
      Oregon3.446.6010.27
      Pennsylvania5.61−0.884.68
      Puerto Rico6.640.016.65
      Rhode Island2.01−1.160.83
      South Carolina−2.876.983.91
      South Dakota4.391.616.07
      Tennessee3.191.704.95
      Texas6.591.608.30
      Utah17.015.0822.95
      Vermont3.302.015.38
      Virginia1.0211.3412.48
      Washington4.50−0.543.94
      West Virginia3.5616.5020.65
      Wisconsin−1.051.060.00
      Wyoming0.224.274.50
      Total9.498.7919.12

       Data Challenges and Limitations

      This study necessitated the use of a variety of data sources to account for differences in state data collection and data availability. Given this variation, several challenges emerged related to reconciling state-reported data with NCHS data, missing data, and differences in how the data were collected, among others. These challenges present some limitations in the results summarized herein.

       Vital records data

      Owing to the timing of reporting and the specificity of collecting resident birth data, there are discrepancies (in the range of 0.01%–5%) between the number of total births reported by states and the NCHS data. The discrepancies are usually small and mostly related to births to residents that took place out of state. To calculate the percentages of Medicaid births, we used state-reported total birth counts (as opposed to NCHS birth counts) to reduce bias and reflect discrepancies related to out-of-state births in both the numerator and the denominator.
      Because two thirds of all states have adopted the 2003 birth certificate, most states provided birth frequencies using vital records data. We used resident birth counts as opposed to occurrence data because we found it was the most common approach in birth data reporting and it better served the scope of our research. Resident births are “births occurring within the United States to U.S. citizens and to residents who are not citizens, allocated to the usual place of residence of the mother in the United States” (

      U.S. Centers for Disease Control and Prevention. (2010). User guide to the 2010 Natality Public Use File [data file]. Retrieved from ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataet_Documentation/DVS/natality/UserGuide2010.pdf.

      ). Births to U.S. residents occurring outside the United States and births to non-U.S. residents (included usually in occurrence birth data) are not included in resident birth frequencies, which suited our need for U.S. birth counts. However, the use of resident data has its own challenges in addition to the general vital statistics data limitations, as follows.

       Time lag for reporting

      The 50 states, District of Columbia, Puerto Rico, Virgin Islands, Guam, and Canadian provinces have an agreement allowing for the exchange of statistical copies of birth and death records for events occurring in a state other than the state of residence (

      Massachusetts Department of Public Health. (2013). Massachusetts births 2010. Retrieved from http://www.mass.gov/eohhs/docs/dph/research-epi/birth-report-2010.pdf.

      ). This exchange causes a lag between the time the state calculates the in-state resident birth and the out-of-state births. For example, Utah was only able to provide in-state Medicaid resident birth counts.

       Missing/unknown payment source

      Some states (GA, MT, NM, OH, TN, WV) and the District of Columbia reported resident birth counts with a large number of unknowns (up to 30%; Table 4). The unknowns are generally owing to out-of-state deliveries, because birth certificates from the surrounding states may not include a payer question.
      Table 4States With the Highest Percentage of Births With Unknown Payment Source
      State
      NM did not provide a precise figure for births from Vital Statistics, but estimated the unknown answers at 25% to 30% of all birth certificates (see Hospital Discharge Data).
      Percent of Unknown Answers
      200820092010
      District of Columbia
      The District of Columbia adopted the 2003 birth certificate in 2009.
      24.099.16
      Georgia23.5214.7411.57
      Montana9.887.572.43
      Ohio4.184.574.08
      Tennessee3.764.395.14
      West Virginia25.8825.3213.58
      NM did not provide a precise figure for births from Vital Statistics, but estimated the unknown answers at 25% to 30% of all birth certificates (see Hospital Discharge Data).
      The District of Columbia adopted the 2003 birth certificate in 2009.

       Self-reported data

      It is important to note that the payer information on the standard birth certificate is provided by the mother and represents her expectation for payment for delivery. The 2003 certificate asks for source of payment and provides fours options: Medicaid, private insurance, self-pay, and other.
      Some states that have not adopted the revised birth certificate have added their own question to the 1989 birth certificate, such as “Are you eligible/do you qualify for medical assistance?.” In the majority of cases, the form is completed by a hospital nurse based on insurance information. However, the question still registers expectations rather than actual payment, even if based on an existing insurance policy. In addition, even though the nurses fill in the information based on insurance card validation for the cases of emergency Medicaid, the claim is not settled until at least 30 days after birth; in some cases, Medicaid may not be the final payer despite being listed on the birth certificate.

       Different payer questions

      Some states (MD, MS, NC, OK, UT) and the District of Columbia adopted the 2003 certificate in the middle of our data collection period, either in 2009 or 2010, thereby producing inconsistencies in the data within a state over time as the questions changed. In addition, states that have added their own payer questions before adopting the new certificate format had a wide variation in the types of questions used (Figure 2).
      Figure thumbnail gr2
      Figure 2Examples of state-added birth certificate payment questions.
      Questions ranged from asking about the Medicaid coverage of the birth to inquiring about Medicaid eligibility in general or Medicaid eligibility at any time during the pregnancy.

       Implementation challenges

      Birth statistics by payer may also be inconsistent from year to year owing to challenges in the initial implementation of the 2003 certificate. The first year of reporting usually does not yield reliable data as providers adjust to the new forms. Additionally, the certificate may not be adopted by the calendar year. In the District of Columbia, for example, the 2003 certificate was not in circulation until after the start of the 2009 calendar year and the data for 2009 exclude January.

       Medicaid data

      The majority of the 17 states that have not adopted the 2003 birth certificate reported Medicaid birth frequencies from state Medicaid databases, based either on Medicaid claims data or on Medicaid eligibility. The major difference between the two is that Medicaid claims represent an actual payment for services rather than an expectation for such. Presumptive eligibility allows individuals to use Medicaid funds for services while their application is being processed, which takes about a month. In those cases, even if Medicaid is listed as a payer, it may not actually pay for the service if the individual is ineligible. An option for pending Medicaid eligibility is not provided in the 2003 birth certificate, although, for example, Maryland had such an option in its earlier version of the payment question (Figure 2). Similarly, individuals who provide no payment source or another payment source often eventually have their delivery costs covered by Medicaid. An additional challenge with the Medicaid data relates to eligibility based on mother versus child. In some cases, a mother whose delivery was covered by Medicaid or who was covered for her pregnancy through fetal coverage through the Children's Health Insurance Program offered by states who have taken up the Children's Health Insurance Program “unborn child” coverage option may not be eligible for Medicaid, but the child would qualify owing to a higher income threshold for children (

      Dailard, C. (2002). New SCHIP prenatal care rule advances fetal rights at low-income women's expense. The Guttmacher Report on Public Policy, Vol 5, No. 5, Retrieved from: http://www.guttmacher.org/pubs/tgr/05/5/gr050503.html.

      ,

      Kaiser Commission on Medicaid and the Uninsured. (2012), Where are states today: Medicaid and CHIP eligibility levels for children and non-disabled adults. Retrieved from http://www.kff.org/medicaid/upload/7993-02.pdf.

      ). In these cases, inconsistencies in reporting may result from lack of clarity on the forms about whether Medicaid should cover delivery or just newborn care.

       Number of newborns versus number of deliveries

      States can report on Medicaid deliveries or on the number of newborns. The two numbers do not always match given twin and multiple births, but states can account for the discrepancy using Medicaid newborn claims. However, Medicaid does not pay separately for newborn care in states with capitated payments. To account for all and provide for accurate counts, providers must submit a $0 claim for each newborn, which often does not happen in practice. In our research, all states except Arkansas reported Medicaid deliveries, which is a more accurate number for the needs of our study.

       Hospital discharge data

      Hospital discharge data can also be a source for Medicaid birth data. Hospital discharge data are limited to in-state deliveries and do not include home deliveries (which tend to be negligible in number). However, it can be of superior quality to other data sources in states with large numbers of unknowns, such as New Mexico, for example, where not all hospitals report payer data on the birth certificate and the unknowns from birth records are 25% to 35%.

       Linked datasets for Medicaid births

      At least six states have linked birth records with Medicaid data to generate Medicaid birth frequencies. In Alaska, Connecticut, Minnesota, and Nevada, birth records are linked with Medicaid eligibility information, whereas in Iowa and North Carolina the linkage is with Medicaid claims data. Linkages with Medicaid claims should provide the highest quality data, because once the claim has been processed the confirmed source of payment is Medicaid, a clear benefit over self-reported data. However, this is not always possible and can be cumbersome for states, because the organizational structure of the state health departments may not support collaboration between the Health Statistics unit and the Medicaid agency. In North Carolina, for example, such cooperation exists owing to years of collaboration between the state's Health Statistics unit and the Medicaid agency, which have worked together on a number of projects and have an established partnership that facilitates data sharing.

      Discussion

      Our research shows that none of the current reporting systems is ideal, each with its own challenges and limitations. In addition, the use of three different data collection and reporting systems cannot yield reliable national figures and limits the consistency in the reported numbers. Consistent adoption of the 2003 certificate in all states would allow the NCHS Natality Detail dataset to serve as a nationally representative source of data for the financing of births in the United States, once the challenges of the initial implementation are resolved. The U.S. Centers for Disease Control and Prevention NCHS is currently working with states who have yet to implement the 2003 certificate to expedite adoption of the certificate, and thus availability of a uniform method for obtaining payer source data. For states that previously used Vital Records to collect payer information but only recently adopted the 2003 certificate, the difference in counts owing to the question format changes will diminish over time. In addition, vital record linkages with Medicaid data systems provide the highest quality data. However, the small number of states that have attempted data linkage demonstrates the inherent challenges. With the implementation of the ACA, there will be a continued need for accurate, timely, and uniform reporting on maternity coverage in Medicaid and in the health insurance exchanges. State health departments should work to build linkages between Vital Records and Medicaid data systems, and specifically Medicaid claims.

       Implications for Practice and/or Policy

      Although nearly half of births are financed by Medicaid, historically very few nonpregnant women have been eligible for Medicaid coverage. A 2012 study of health insurance coverage for women of reproductive age found that 19% of nonpregnant women were currently uninsured in 2009, with only 8% receiving coverage through Medicaid (
      • Kozihimannil K.B.
      • Abraham J.M.
      • Virnig B.A.
      National trends in health insurance coverage of pregnant and reproductive-age women, 2000 to 2009.
      ). Under health care reform, states have the option to expand Medicaid coverage to low-income women regardless of pregnancy status. This option has significant implications for Medicaid-financed birth outcomes and costs. As states expand coverage to low-income women, women of childbearing age will be able to obtain coverage before and between pregnancies, allowing for access to services that could improve their overall and reproductive health as well as birth outcomes (

      Pellegrini, C., & Garro, N. (2013). Medicaid expansion: Benefits for women of childbearing age and their children. Retrieved from: http://healthaffairs.org/blog/2013/02/22/medicaid-expansion-benefits-for-women-of-childbearing-age-and-their-children/.

      ). Likewise, improved birth outcomes could translate into substantial cost savings, because the costs associated with preterm births are estimated to be 10 times greater than for full-term births (
      Institute of Medicine
      Preterm birth: Causes, consequences and prevention.
      ). Medicaid covers complex births disproportionately: Medicaid paid for over half of all hospital stays for preterm and low birth weight infants, and about 45% of infant hospital stays owing to birth defects in 2009 (

      Agency for Healthcare Research and Quality. (2012). Healthcare Cost and Utilization Project (HCUP), 2012. Available at: http://www.ahrq.gov/research/data/hcup/index.html.

      ). To understand the effects of Medicaid expansions and changes moving forward, including its effect on cost, quality, access, and health outcomes, it is important to have a clear sense of Medicaid's contribution in the current context and how this contribution may evolve in the near future.

      Acknowledgments

      We are grateful for support provided by the March of Dimes .

      References

      1. Agency for Healthcare Research and Quality. (2012). Healthcare Cost and Utilization Project (HCUP), 2012. Available at: http://www.ahrq.gov/research/data/hcup/index.html.

      2. Dailard, C. (2002). New SCHIP prenatal care rule advances fetal rights at low-income women's expense. The Guttmacher Report on Public Policy, Vol 5, No. 5, Retrieved from: http://www.guttmacher.org/pubs/tgr/05/5/gr050503.html.

      3. Guttmacher Institute. (2013). State data center. Retrieved from http://www.guttmacher.org/datacenter/servlet/CreateTable?action=doTable; http://www.guttmacher.org/media/inthenews/2010/09/17/index.html.

        • Heberlein M.
        • Brooks T.
        • Alker J.
        • Artiga S.
        • Stephens J.
        Getting into gear for 2014: Findings from a 50-state survey of eligibility, enrollment, renewal, and cost-sharing policies in Medicaid and CHIP, 2012–2013.
        Kaiser Commission on Medicaid and the Uninsured, Washington, DC2013
        • Institute of Medicine
        Preterm birth: Causes, consequences and prevention.
        National Academy Press, Washington, DC2006
      4. Kaiser Commission on Medicaid and the Uninsured. (2012), Where are states today: Medicaid and CHIP eligibility levels for children and non-disabled adults. Retrieved from http://www.kff.org/medicaid/upload/7993-02.pdf.

        • Kaiser Commission on Medicaid and the Uninsured
        Medicaid: A primer.
        Kaiser Family Foundation, Washington, DC2013
      5. Kaiser Family Foundation. (2011). Women’s Health Care Chartbook: Key Findings from Kaiser Women’s Health Survey. Washington, DC: Author.

      6. Kaiser Family Foundation. (2012). Medicaid’s role for women across the lifespan: Current issues and the impact of the Affordable Care Act. Women’s issue brief. Washington, DC: Author.

        • Kenney G.
        • Zuckerman S.
        • Dubay L.
        • Huntress M.
        • Lynch V.
        • Haley J.
        • et al.
        Opting in to the Medicaid expansion under ACA: Who are the uninsured who could gain health insurance coverage. Timely analysis of immediate health policy issues.
        The Urban Institute, Washington, DC2012
        • Kozihimannil K.B.
        • Abraham J.M.
        • Virnig B.A.
        National trends in health insurance coverage of pregnant and reproductive-age women, 2000 to 2009.
        Women’s Health Issues. 2012; 22: e135-e141
      7. Massachusetts Department of Public Health. (2013). Massachusetts births 2010. Retrieved from http://www.mass.gov/eohhs/docs/dph/research-epi/birth-report-2010.pdf.

      8. National Governors Association (NGA). (2010). Maternal and child health update: States make progress towards improving systems of care. Issue Brief [see Table 6]. Retrieved from: http://www.nga.org/files/live/sites/NGA/files/pdf/MCHUPDATE2010.PDF.

      9. National Governors’ Association (NGA). (2011). 2010 Maternal and child health update: States makes progress towards improving systems of care. Retrieved from http://www.nga.org/files/live/sites/NGA/files/pdf/MCHUPDATE2010.PDF.

      10. Pellegrini, C., & Garro, N. (2013). Medicaid expansion: Benefits for women of childbearing age and their children. Retrieved from: http://healthaffairs.org/blog/2013/02/22/medicaid-expansion-benefits-for-women-of-childbearing-age-and-their-children/.

        • Sommers B.
        • Rosenbaum S.
        Issues in health reform: How changes in eligibility may move millions back and forth between Medicaid and insurance exchanges.
        Health Affairs. 2011; 30: 228-236
        • Sonfield A.
        • Kost K.
        • Benson Gold R.
        • Finer L.
        The public costs of births resulting from unintended pregnancies: National and state-level estimates.
        Perspectives on Sexual and Reproductive Health. 2011; 43: 93-102
        • Stranges E.
        • Wier L.
        • Elixhauser A.
        Complicating conditions of vaginal deliveries and cesarean sections, 2009. HCUP Statistical Brief #131.
        Agency for Healthcare Research and Quality, Rockville, MD2012
      11. U.S. Centers for Disease Control and Prevention. (2010). User guide to the 2010 Natality Public Use File [data file]. Retrieved from ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataet_Documentation/DVS/natality/UserGuide2010.pdf.

      Biography

      Anne Rossier Markus, JD, PhD, MHS, is Associate Professor in the Department of Health Policy of the George Washington University's School of Public Health and Health Services. Anne directs the Department's child health policy research and analysis portfolio and focuses on topics related to the financing and organization of health care and access to quality care, with a special emphasis on domestic and international policies that affect women and children's health and well-being.
      Ellie Andres, MPH, DrPH-c, is a Senior Research Associate and doctoral candidate in the Department of Health Policy of the George Washington University's School of Public Health and Health Services. Her research interests include maternal and child health, community health centers, and policies that affect women, such as the Family and Medical Leave Act of 1993.
      Kristina D. West, JD, MS Health Policy Candidate is a Senior Research Associate at the Department of Health Policy, School of Public Health and Health Services, The George Washington University. Her research interests are in maternal and child health policy.
      Nicole Garro, MPH, Director of Public Policy Research at the March of Dimes, oversees the March of Dimes' maternal and child health policy research agenda, which informs advocacy for programs and policies that promote positive health outcomes for women and children.
      Cynthia Pellegrini, BA, is Senior Vice President for Public Policy and Government Affairs at the March of Dimes, responsible for guiding March of Dimes advocacy efforts at the federal level and in all 50 States, the District of Columbia and Puerto Rico.

      Linked Article

      • Erratum
        Women's Health IssuesVol. 23Issue 6
        • Preview
          Refers to: “Medicaid Covered Births, 2008 Through 2010, in the Context of the Implementation of Health Reform,” Anne Rossier Markus, JD, PhD, MHS, Ellie Andres, MPH, DrPH-c, Kristina D. West, JD, Nicole Garro, MPH, Cynthia Pellegrini, BA. Women's Health Issues, Volume 23, Issue 5, Pages e273-e280, September 2013.
        • Full-Text
        • PDF