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Extending Delivery Coverage to Include Prenatal Care for Low-Income, Immigrant Women Is a Cost-Effective Strategy

Published:April 03, 2020DOI:https://doi.org/10.1016/j.whi.2020.02.004

      Abstract

      Objective

      To compare the outcomes and cost effectiveness of two alternate policy strategies for prenatal care among low-income, immigrant women: coverage for delivery only (the federal standard) and prenatal care with delivery coverage (state option under the Children's Health Insurance Program).

      Methods

      A decision-analytic model was developed to determine the cost effectiveness of two alternate policies for pregnancy coverage. All states currently provide coverage for delivery, and 19 states also provide coverage for prenatal care. An estimated 84,000 unauthorized immigrant women have pregnancies where no prenatal care is covered. Our outcomes were costs, quality-adjusted life-years, and cases of cerebral palsy and infant death before age 1. Model inputs were obtained from a database of Oregon Medicaid claims and the literature. Univariate and bivariate sensitivity analyses, as well as a Monte Carlo simulation, were performed.

      Results

      Extending prenatal coverage is a cost-effective strategy. Providing prenatal care for the 84,000 women annually who are currently uninsured could prevent 117 infant deaths and 34 cases of cerebral palsy. Prenatal care coverage costs $380 more per woman than covering the delivery only. For every 865 additional women receiving prenatal care, one infant death would be averted, at an average cost of $328,700. Cost-effectiveness acceptability curve analyses suggest a 99% probability that providing prenatal care is more cost effective at a willingness-to-pay threshold of $100,000 per quality-adjusted life-year.

      Conclusions

      Extending prenatal care to low-income, immigrant women, regardless of citizenship status, is a cost-effective strategy.
      Health care during pregnancy is essential to the well-being of women and children (
      American Academy of Pediatrics
      Guidelines for perinatal care. American Academy of Pediatrics. American College of Obstetricians and Gynecologists.
      ,
      • United Nations
      United Nations Millennium Development Goals.
      ,
      • World Health Organization (WHO)
      WHO recommendations on health promotion interventions for maternal and newborn health 2015. WHO.
      ). Prenatal care is an opportunity to manage chronic diseases, identify and treat pregnancy-related conditions, and provide health education (
      American Academy of Pediatrics
      Guidelines for perinatal care. American Academy of Pediatrics. American College of Obstetricians and Gynecologists.
      ,
      • Carroli G.
      • Rooney C.
      • Villar J.
      How effective is antenatal care in preventing maternal mortality and serious morbidity? An overview of the evidence.
      ,
      • Huntington J.
      • Connell F.A.
      For every dollar spent – The cost-savings argument for prenatal care.
      ,
      • Mbuagbaw L.
      • Medley N.
      • Darzi A.J.
      • Richardson M.
      • Habiba Garga K.
      • Ongolo-Zogo P.
      Health system and community level interventions for improving antenatal care coverage and health outcomes.
      ). For infants, prenatal care functions as a preventive measure, lowering risks of low birthweight, preterm birth, stillbirth, and neonatal death (
      • Lu M.C.
      • Lin Y.G.
      • Prietto N.M.
      • Garite T.J.
      Elimination of public funding of prenatal care for undocumented immigrants in California: A cost/benefit analysis.
      ,
      • Mbuagbaw L.
      • Medley N.
      • Darzi A.J.
      • Richardson M.
      • Habiba Garga K.
      • Ongolo-Zogo P.
      Health system and community level interventions for improving antenatal care coverage and health outcomes.
      ,
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Expanding prenatal care to unauthorized immigrant women and the effects on infant health.
      ,
      • Vintzileos A.M.
      • Ananth C.V.
      • Smulian J.C.
      • Scorza W.E.
      • Knuppel R.A.
      The impact of prenatal care in the United States on preterm births in the presence and absence of antenatal high-risk conditions.
      ).
      However, access to prenatal care is restricted for populations who may benefit substantially from it: low-income, immigrant women and their children (
      • Wherry L.R.
      • Fabi R.
      • Schickedanz A.
      • Saloner B.
      State and Federal coverage for pregnant immigrants: Prenatal care increased, no change detected for infant health.
      ). In the United States, Medicaid is a program providing public insurance for the financially needy that is jointly funded by state and federal dollars. To qualify for Medicaid, in addition to meeting financial eligibility criteria, women must be citizens or permanent residents residing in the United States for more than 5 years. Unauthorized immigrants and recently arrived legal permanent residents are eligible for Emergency Medicaid only (
      • Derose K.P.
      • Escarce J.J.
      • Lurie N.
      Immigrants and health care: Sources of vulnerability.
      ). As compared with traditional Medicaid, which provides comprehensive prenatal, intrapartum, and postpartum care, Emergency Medicaid provides coverage only for life-threatening conditions or an admission for childbirth (
      • DuBard C.A.
      • Massing M.W.
      Trends in emergency Medicaid expenditures for recent and undocumented immigrants.
      ). Prenatal care and postpartum care are excluded. Medicaid is the largest payer for obstetric services nationally, covering nearly one-half of all births (
      • Bellamy L.
      • Casas J.-P.
      • Hingorani A.D.
      • Williams D.
      Type 2 diabetes mellitus after gestational diabetes: A systematic review and meta-analysis.
      ,
      • Markus A.R.
      • Andres E.
      • West K.D.
      • Garro N.
      • Pellegrini C.
      Medicaid covered births, 2008 through 2010, in the context of the implementation of health reform.
      ,
      • Martin J.A.
      • Hamilton B.E.
      • Osterman M.J.K.
      Births in the United States, 2017 (NCHS Data Brief No. 318; NCHS Data Brief). CDC.
      ).
      Recognizing that children born in the United States are full citizens and entitled to full-scope Medicaid, the Unborn Child Clause of the Children's Health Insurance Program (CHIP) permits states to extend prenatal care coverage to immigrant women, with the purpose of benefiting the future citizens. As of 2019, 16 states offer women qualifying for Emergency Medicaid access to prenatal care under the CHIP's Unborn Child option and two additional states and Washington, DC, use state and local funding (Supplemental Table 1) (
      • Department of Human Services
      Pregnant women.
      , ,
      Kaiser Family Foundation
      Where are states today? Medicaid and CHIP eligibility levels for children, pregnant women, and adults. The Henry J. Kaiser Family Foundation.
      ,
      • New York City Human Resources Administration
      Immigrants—OCHIA.
      ,
      • Wherry L.R.
      • Fabi R.
      • Schickedanz A.
      • Saloner B.
      State and Federal coverage for pregnant immigrants: Prenatal care increased, no change detected for infant health.
      ).
      We previously evaluated the health impact of introducing prenatal care coverage to this population in Oregon, and demonstrated that prenatal care significantly improved both health care use and outcomes (
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Expanding prenatal care to unauthorized immigrant women and the effects on infant health.
      ,
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Oregon’s expansion of prenatal care improved utilization among immigrant women.
      ). Specifically, prenatal care coverage improved adequacy of care, receipt of basic obstetric services (e.g., diabetes screening), and diagnosis of high-risk conditions (e.g., poor fetal growth, chronic hypertension, diabetes, and prior preterm birth) (
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Oregon’s expansion of prenatal care improved utilization among immigrant women.
      ). Infant outcomes were improved with a decrease in extremely low birthweight infants and infant mortality before age one (
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Expanding prenatal care to unauthorized immigrant women and the effects on infant health.
      ).
      Previous work has demonstrated that restricting access to postpartum care, in particular contraception, by citizenship status is not a cost-effective strategy (
      • Rodriguez M.I.
      • Caughey A.B.
      • Edelman A.
      • Darney P.D.
      • Foster D.G.
      Cost-benefit analysis of state- and hospital-funded postpartum intrauterine contraception at a university hospital for recent immigrants to the United States.
      ,
      • Rodriguez M.I.
      • Jensen J.T.
      • Darney P.D.
      • Little S.E.
      • Caughey A.B.
      The financial effects of expanding postpartum contraception for new immigrants.
      ). The cost effectiveness of prenatal care coverage in this population is not known. We therefore sought to compare the outcomes and estimate cost-effectiveness of two alternate policy strategies for prenatal care among low-income, immigrant women: coverage for delivery only (the federal standard) and prenatal care with delivery coverage (state option under the CHIP's Unborn Child option).

      Methods

      A decision-analytic model was developed using TreeAge software (Figure 1, TreeAge Software, Williamstown, MA). A decision analysis allows incremental comparison of probabilities and outcomes of different choices or policies. A cost-effectiveness analysis measures the incremental costs and outcomes that result from choosing one option over another, providing the comparative advantage of each strategy (
      • Rodriguez M.I.
      • Caughey A.B.
      Cost-effectiveness analyses and their role in improving healthcare strategies.
      ). We compared the policy of coverage of prenatal care for women enrolled in Emergency Medicaid with the federal standard of covering an admission for childbirth only. Our perspective was a payer perspective, specifically that of state Medicaid programs. We assessed outcomes for a theoretical cohort: immigrant women living in states where Emergency Medicaid covers a delivery only. We chose outcomes with public health and policy relevance. We also limited ourselves to health outcomes we were able to determine using Medicaid claims. Our primary outcomes were: costs, quality-adjusted life-years (QALYs), and averted cases of infant death and children with moderate to severe disability attributed to cerebral palsy. The sequence of the model begins with a pregnant woman who has a desired pregnancy in the first trimester. Figure 1 shows one branch of the decision model, proceeding to each of the evaluated costs and outcomes. Pregnancy and neonatal outcomes were evaluated at time of delivery. The Institutional Review Boards from Oregon Health & Science University and Stanford University approved our study protocol. This research is reported in accordance with Consolidated Health Economic Evaluation Reporting Standards (
      • Husereau D.
      • Drummond M.
      • Petrou S.
      • Carswell C.
      • Moher D.
      • Greenberg D.
      • Loder E.
      Consolidated health economic evaluation reporting standards (CHEERS)—explanation and elaboration: A report of the ISPOR health economic evaluation publication guidelines good reporting practices task force.
      ).
      Figure thumbnail gr1
      Figure 1Cost-effectiveness model comparing covered prenatal care versus coverage for labor and delivery only for recipients of Emergency Medicaid. The theoretical model included women who had Emergency Medicaid for pregnancy and delivery coverage. Standard federal Emergency Medicaid does not include coverage for prenatal or postpartum care, but some states offer this coverage under a provision of the Children's Health Insurance Program. Outcomes evaluated include low birthweight, children affected by moderate to severe disability from cerebral palsy, and infant death.
      To estimate the cohort of unauthorized immigrant women who are pregnant in the 32 states where prenatal care is not covered, we used the Center for Migration Studies estimates of the number of unauthorized immigrants in states that have not adopted the CHIP expansion or extended state funding (Supplemental Table 1) (
      • Center for Migration Studies
      State tool.
      ). We calculated the number of immigrant women ages 18 to 44 living in these states (n = 1,120,000). We then used data from the American Community Survey, which indicates that 7.5% of foreign-born women have given birth in the past year (
      • Radford J.
      • Noe-Bustamonte L.
      Immigrants in America: Current data and demographics. Pew Research Center’s Hispanic Trends Project.
      ). We assumed that a similar proportion (7.5%) of unauthorized immigrant women in this age range living in these states would be pregnant, resulting in a theoretical cohort of 84,000 (Supplemental Table 2). This represents a conservative estimate of the population of immigrant women giving birth in states without prenatal coverage; the cohort estimate does not include immigrant women under age 18 or authorized immigrant women who are ineligible for Medicaid because they have not yet resided in the United States for 5 years.

      Probability and Cost Inputs

      Probability and cost inputs were obtained from a database of medical claims data and from the literature (Table 1). We obtained medical claims data from January 1, 2003, through October 1, 2015, from the Oregon Health Authority's Department of Health Analytics. Claims data included Medicaid, Emergency Medicaid, and Emergency Medicaid with prenatal care, which we will refer to as Emergency Medicaid Plus. A description of the methods to construct the database, identify pregnancy episodes, and link women with infants has been detailed elsewhere (
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Expanding prenatal care to unauthorized immigrant women and the effects on infant health.
      ). In brief, we developed an algorithm to identify pregnancy episodes based on Current Procedural Terminology and International Classification of Diseases, Ninth Revision, codes and a household identification number and auxiliary identifiers to match women and infants. We then used International Classification of Diseases, Ninth Revision, and Current Procedural Terminology codes from the claims file to ascertain the frequency of a number of prospectively identified outcomes (
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Expanding prenatal care to unauthorized immigrant women and the effects on infant health.
      ). This analysis focuses on adverse outcomes for which prenatal care was found to be protective, rather than outcomes for which we did not see a significant effect (
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Expanding prenatal care to unauthorized immigrant women and the effects on infant health.
      ,
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Oregon’s expansion of prenatal care improved utilization among immigrant women.
      ). In no case was access to prenatal care associated with an adverse effect (
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Expanding prenatal care to unauthorized immigrant women and the effects on infant health.
      ,
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Oregon’s expansion of prenatal care improved utilization among immigrant women.
      ). The probability of death in the first year of life and birthweight of less than 1000 g were obtained from our prior study (
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Expanding prenatal care to unauthorized immigrant women and the effects on infant health.
      ). The probability of severe to moderate disability for infants with birthweight of less than 1000 g was obtained from the literature and used as one of our primary outcomes (
      • Johnson S.
      • Fawke J.
      • Hennessy E.
      • Rowell V.
      • Thomas S.
      • Wolke D.
      • Marlow N.
      Neurodevelopmental disability through 11 years of age in children born before 26 weeks of gestation.
      ,
      • Oskoui M.
      • Coutinho F.
      • Dykeman J.
      • Jetté N.
      • Pringsheim T.
      An update on the prevalence of cerebral palsy: A systematic review and meta-analysis.
      ,
      • Wood N.S.
      • Marlow N.
      • Costeloe K.
      • Gibson A.T.
      • Wilkinson A.R.
      Neurologic and developmental disability after extremely preterm birth. EPICure Study Group.
      ).
      Table 1Base Estimates for Model
      VariableBase EstimateSource
      Probabilities
       Probability of having a high-risk pregnancy0.06
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Oregon’s expansion of prenatal care improved utilization among immigrant women.
       Probability of birthweight <1000 g0.004619
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Expanding prenatal care to unauthorized immigrant women and the effects on infant health.
       Probability of birthweight >1000 g and <2500 g0.057082
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Expanding prenatal care to unauthorized immigrant women and the effects on infant health.
       Decrease in likelihood of birthweight <1000 g−0.00133
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Expanding prenatal care to unauthorized immigrant women and the effects on infant health.
       Probability of survival if birthweight <1000 g0.8267
      • Manktelow B.N.
      • Seaton S.E.
      • Field D.J.
      • Draper E.S.
      Population-based estimates of in-unit survival for very preterm infants.
       Probability of survival if birthweight >1000 g and <2500 g0.985
      • Manktelow B.N.
      • Seaton S.E.
      • Field D.J.
      • Draper E.S.
      Population-based estimates of in-unit survival for very preterm infants.
       Probability of survival if birthweight >2500 g0.9975
      • Swamy G.K.
      Association of preterm birth with long-term survival, reproduction, and next-generation preterm birth.
       Probability of moderate to severe long-term disability if <1000 g0.4
      • Johnson S.
      • Fawke J.
      • Hennessy E.
      • Rowell V.
      • Thomas S.
      • Wolke D.
      • Marlow N.
      Neurodevelopmental disability through 11 years of age in children born before 26 weeks of gestation.
      ,
      • Oskoui M.
      • Coutinho F.
      • Dykeman J.
      • Jetté N.
      • Pringsheim T.
      An update on the prevalence of cerebral palsy: A systematic review and meta-analysis.
      ,
      • Wood N.S.
      • Marlow N.
      • Costeloe K.
      • Gibson A.T.
      • Wilkinson A.R.
      Neurologic and developmental disability after extremely preterm birth. EPICure Study Group.
       Probability of moderate to severe long-term disability if >1000 g and <2500 g0.034
      • Oskoui M.
      • Coutinho F.
      • Dykeman J.
      • Jetté N.
      • Pringsheim T.
      An update on the prevalence of cerebral palsy: A systematic review and meta-analysis.
       Probability of moderate to severe long-term disability if >2500 g0.0013
      Committee on Obstetric Practice
      Committee Opinion No. 687: Approaches to limit intervention during labor and birth.
      ,
      • Oskoui M.
      • Coutinho F.
      • Dykeman J.
      • Jetté N.
      • Pringsheim T.
      An update on the prevalence of cerebral palsy: A systematic review and meta-analysis.
       Reduction in probability of death with access to prenatal care−0.00103
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Expanding prenatal care to unauthorized immigrant women and the effects on infant health.
       Low-risk pregnancy risk of stillbirth0.003923
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Expanding prenatal care to unauthorized immigrant women and the effects on infant health.
       Low-risk pregnancy average number of prenatal visits7.2755
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Expanding prenatal care to unauthorized immigrant women and the effects on infant health.
       High-risk pregnancy risk of stillbirth0.005429
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Expanding prenatal care to unauthorized immigrant women and the effects on infant health.
       High-risk pregnancy average number of prenatal visits8.6167
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Expanding prenatal care to unauthorized immigrant women and the effects on infant health.
      Utilities
       Utility of infant death for mother0.9
      • Partridge J.C.
      • Sendowski M.D.
      • Martinez A.M.
      • Caughey A.B.
      Resuscitation of likely nonviable infants: A cost-utility analysis after the Born-Alive Infant Protection Act.
       Utility of moderate to severe neonatal disability for the mother0.75
      • Partridge J.C.
      • Sendowski M.D.
      • Martinez A.M.
      • Caughey A.B.
      Resuscitation of likely nonviable infants: A cost-utility analysis after the Born-Alive Infant Protection Act.
       Utility of moderate to severe disability for the infant0.55
      • Cahill A.G.
      • Odibo A.O.
      • Stout M.J.
      • Grobman W.A.
      • Macones G.A.
      • Caughey A.B.
      Magnesium sulfate therapy for the prevention of cerebral palsy in preterm infants: A decision-analytic and economic analysis.
      Costs (rounded to nearest dollar)
       Prenatal visit210
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Expanding prenatal care to unauthorized immigrant women and the effects on infant health.
       Ultrasound examination184
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Expanding prenatal care to unauthorized immigrant women and the effects on infant health.
       Non-stress test147
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Expanding prenatal care to unauthorized immigrant women and the effects on infant health.
       Vaginal delivery for low-risk pregnancy5,300
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Expanding prenatal care to unauthorized immigrant women and the effects on infant health.
       Vaginal delivery for high-risk pregnancy5,852
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Expanding prenatal care to unauthorized immigrant women and the effects on infant health.
       Cesarean delivery for low-risk pregnancy8,341
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Expanding prenatal care to unauthorized immigrant women and the effects on infant health.
       Cesarean delivery for high-risk pregnancy9,098
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Expanding prenatal care to unauthorized immigrant women and the effects on infant health.
       Stillbirth after low-risk pregnancy7,455
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Expanding prenatal care to unauthorized immigrant women and the effects on infant health.
       Stillbirth after high-risk pregnancy10,367
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Expanding prenatal care to unauthorized immigrant women and the effects on infant health.
       Infant death
      Weighted for gestational age.
      139,585
      • Phibbs C.S.
      • Schmitt S.K.
      Estimates of the cost and length of stay changes that can be attributed to one-week increases in gestational age for premature infants.
       Long-term care for moderate to severe disability1,443,683
      • Partridge J.C.
      • Sendowski M.D.
      • Martinez A.M.
      • Caughey A.B.
      Resuscitation of likely nonviable infants: A cost-utility analysis after the Born-Alive Infant Protection Act.
       Hospital care for infants <1000 g that die139,584
      • Phibbs C.S.
      • Schmitt S.K.
      Estimates of the cost and length of stay changes that can be attributed to one-week increases in gestational age for premature infants.
       Hospital care for infants >1000 g and <2500 g that die164,113
      • Phibbs C.S.
      • Schmitt S.K.
      Estimates of the cost and length of stay changes that can be attributed to one-week increases in gestational age for premature infants.
       Hospital care for infants <1000 g that survive398,858
      • Phibbs C.S.
      • Schmitt S.K.
      Estimates of the cost and length of stay changes that can be attributed to one-week increases in gestational age for premature infants.
       Hospital care for infants >1000 g and <2500 g that survive141,087
      • Phibbs C.S.
      • Schmitt S.K.
      Estimates of the cost and length of stay changes that can be attributed to one-week increases in gestational age for premature infants.
      All costs are inflated to 2018 dollars.
      Weighted for gestational age.
      The probability of having a high-risk pregnancy was ascertained from our database based on the frequency with which women had those diagnoses (Table 1). We defined a high-risk pregnancy as women with preexisting diabetes mellitus, gestational diabetes, maternal drug use, hypertensive disease of pregnancy, a history of preterm birth, poor fetal growth, and Rhesus alloimmunization. We selected these conditions because they are relatively common and potentially could be mitigated by receipt of prenatal care.
      CHIP and Medicaid costs for prenatal care visits, routine tests (ultrasound examinations, fetal nonstress tests, laboratory tests, and vaccines), procedures, and deliveries were obtained from our database based on mean amount paid by Emergency Medicaid (Table 1) (
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Expanding prenatal care to unauthorized immigrant women and the effects on infant health.
      ). The costs for cesarean and vaginal births were not considered separately, and our prior analysis found no change in the cesarean delivery rate associated with access to prenatal care (
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Oregon’s expansion of prenatal care improved utilization among immigrant women.
      ). Infant costs for delivery were obtained from the literature (
      • Phibbs C.S.
      • Schmitt S.K.
      Estimates of the cost and length of stay changes that can be attributed to one-week increases in gestational age for premature infants.
      ). The costs of medical care for a disabled child were obtained from the literature (
      • Cahill A.G.
      • Odibo A.O.
      • Stout M.J.
      • Grobman W.A.
      • Macones G.A.
      • Caughey A.B.
      Magnesium sulfate therapy for the prevention of cerebral palsy in preterm infants: A decision-analytic and economic analysis.
      ,
      • Partridge J.C.
      • Sendowski M.D.
      • Martinez A.M.
      • Caughey A.B.
      Resuscitation of likely nonviable infants: A cost-utility analysis after the Born-Alive Infant Protection Act.
      ). All costs were converted to 2018 U.S. dollars according to the medical component of the U.S. Consumer Price Index (
      • U.S. Bureau of Labor Statistics
      Consumer Price index for all urban consumers: Medical care. FRED, Federal Reserve Bank of St. Louis.
      ).

      Utility and QALY Inputs

      QALYs are a standard measure used in decision and cost-effectiveness analyses to assess the impact of a wide range of health outcomes on quality of life. QALYs are the product of both life expectancy and utility. We analyzed maternal and neonatal QALYs to assess the impact of prenatal care coverage on women and children's quality of life. Utility is an empirically derived measure of satisfaction or value for a particular health state (
      • Saigal S.
      • Stoskopf B.L.
      • Feeny D.
      • Furlong W.
      • Burrows E.
      • Rosenbaum P.L.
      • Hoult L.
      Differences in preferences for neonatal outcomes among health care professionals, parents, and adolescents.
      ,
      • Torrance G.W.
      • Furlong W.
      • Feeny D.
      • Boyle M.
      Multi-attribute preference functions. Health Utilities Index.
      ). By convention, utility values range from 0 to 1, with 0 representing death and 1 indicating perfect health. Utilities for maternal and newborn outcomes were obtained from the literature (Table 1). We used an average maternal life expectancy of 50 years after the delivery and newborn life expectancy of 75 years. The decrease in utility that a woman experiences with a fetal loss were incorporated across 25 life years, as done previously in the literature (
      • Bullard K.A.
      • Shaffer B.L.
      • Greiner K.S.
      • Skeith A.E.
      • Rodriguez M.I.
      • Caughey A.B.
      Twenty-week abortion bans on pregnancies with a congenital diaphragmatic hernia: A cost-effectiveness analysis.
      ). QALYs were exponentially discounted at a standard rate of 3% annually (
      • Rodriguez M.I.
      • Caughey A.B.
      Cost-effectiveness analyses and their role in improving healthcare strategies.
      ).

      Sensitivity Analysis

      Sensitivity analysis is used to test how varying one or more model parameter may alter the results. The sensitivity analysis was performed broadly. Univariate and multivariate sensitivity analyses were performed to test model assumptions and determine the consistency of the findings. The univariate sensitivity analysis was performed on all inputs. We varied each input from 50% to 200% of base estimates to identify if any threshold values existed. A threshold value marks the point at which a change in a variable would alter the model's conclusion (
      • Lilford R.J.
      • Pauker S.G.
      • Braunholtz D.A.
      • Chard J.
      Decision analysis and the implementation of research findings.
      ). To determine cost effectiveness, we used a standard threshold of $100,000 per QALY gained (
      • Owens D.K.
      Interpretation of cost-effectiveness analyses.
      ). This threshold is commonly used in developed countries. We calculated incremental cost-effectiveness ratios that compared coverage of prenatal care with only covering labor and delivery services. The incremental cost-effectiveness ratio is a measure of cost-effectiveness that compares the differences between the costs and health outcomes of two competing interventions (
      • Siegel J.E.
      • Weinstein M.C.
      • Russell L.B.
      • Gold M.R.
      Recommendations for reporting cost-effectiveness analyses. Panel on Cost-Effectiveness in Health and Medicine.
      ). A tornado diagram was made to determine which variables had the greatest effect on the model.
      Multivariate sensitivity analyses were also performed. A bivariate sensitivity analysis was performed on variables with threshold values and other key inputs, including the probability of infant death and low birthweight infants (leading to moderate to severe disability). We performed a Monte Carlo simulation using 10,000 trials to evaluate how simultaneous multivariable changes would affect outcomes. Beta distributions were used for probabilities and gamma distributions for costs. The Monte Carlo simulation enabled variation of all probability estimates simultaneously by sampling distributions around the baseline estimate and estimating the terminal node outcomes individually for each trial. Scatter plots were developed to represent uncertainty in results, and a 95% confidence ellipse was generated.

      Results

      Providing prenatal care for low-income women, regardless of citizenship status, is a cost-effective strategy: it improves health outcomes and associated QALYs at a willingness-to-pay threshold of $100,000. We defined our theoretical cohort as the estimated 84,000 unauthorized immigrant women currently living in the 32 states not offering prenatal coverage for Emergency Medicaid enrollees. For the CHIP and Medicaid programs, prenatal care coverage costs $380 more per woman than covering the delivery only (Table 2). This additional coverage would incur a public cost of $66.5 million with an estimated 117 fewer deaths and 34 fewer cases of children with moderate to severe disability associated with cerebral palsy in our theoretical cohort (Table 2). Considering this effect in a number-needed-to-treat framework, for every 865 additional women receiving prenatal care, one infant death would be averted, at a cost of $328,700 for prenatal care. Similarly, 2,564 women would have to receive prenatal care to prevent one case of severe cerebral palsy, at a cost of $974,320 for prenatal care. Overall, providing prenatal care was a cost-effective strategy.
      Table 2Summary of Pregnancy Outcomes and Costs for Individuals and per 84,000 Women
      PolicyCosts (2018 dollars)QALYsInfant Deaths (in First Year of Life)Cases of Moderate to Severe Disability Associated with Cerebral Palsy
      Coverage for delivery only16,25032.9580.000770.0159
      Coverage for delivery and prenatal care16,59632.9430.00060.0155
      Estimated difference+380+.017–0.0001–0.0004
      Cohort total66,500,000+2,922–117–34
      Costs are presented in dollars, inflated for 2018. Figures in the table represent the costs for care and evaluated pregnancy outcomes for two strategies, prenatal care versus coverage for labor and delivery only for recipients of Emergency Medicaid. The table shows the difference in costs and outcomes for individuals and for our theoretical cohort of 84,000 unauthorized immigrant women currently living in 1 of the 32 states that have not extended prenatal care coverage and expected to be pregnant in a single year. See Supplemental Tables 1 and 2 for state policy and cohort size.
      The sensitivity analysis demonstrated that our findings were robust across reasonable ranges for all probabilities, costs, and utilities. Threshold values were identified for key parameters, as to when coverage of prenatal care would be cost saving for public programs. These included the probability of a high-risk pregnancy, prenatal visit costs, and the costs for lifetime medical care of a disabled child. Our estimates remain consistent, barring large variation in the prevalence of high-risk pregnancy. In contrast with the 6% baseline prevalence of high-risk pregnancy among Oregon Emergency Medicaid recipients, more than 59% of the population would have to have a high-risk pregnancy for prenatal care coverage to be a cost-saving rather than cost-effective strategy for public programs. Our definition of a high-risk pregnancy included conditions such as preexisting diabetes mellitus, a history of preterm birth, and hypertensive disorders, conditions that can be mitigated by regular medical care (
      • Allen A.J.
      • Snowden J.M.
      • Lau B.
      • Cheng Y.
      • Caughey A.B.
      Type-2 diabetes mellitus: Does prenatal care affect outcomes?.
      ). If prenatal care is able to decrease complications of high-risk conditions through preventive management by 25%, prenatal care coverage would also be cost saving rather than cost effective for CHIP and Medicaid. Across all other variables, no threshold values were identified in univariate sensitivity analysis.
      Marked variation in prenatal care use and reimbursement exists. We closely examined these variables to evaluate how changes in our base estimates would affect results. We previously observed that women had an average of seven prenatal visits when care was covered (
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Expanding prenatal care to unauthorized immigrant women and the effects on infant health.
      ). If women have four or fewer prenatal visits, prenatal care coverage is cost saving for the state. We then examined how changes in Medicaid reimbursement and number of visits may impact results by performing a two-way sensitivity analysis. Prenatal care coverage remains a cost-effective strategy even when a visit costs $500, if the woman has eight or fewer visits. If the cost for a prenatal care visit was only $150, and women had six or fewer prenatal visits, then extending prenatal care would be a cost-saving strategy for the state. In contrast, if women had seven or more visits, and a prenatal visit cost $125, prenatal care coverage would not be cost saving.
      We have previously demonstrated that extending coverage of prenatal care to the Emergency Medicaid program reduced infant mortality by 0.10% and extremely low birthweight infants by 0.13% in Oregon (
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Expanding prenatal care to unauthorized immigrant women and the effects on infant health.
      ). We examined these variables closely, to ensure our results were generalizable to other populations. Prenatal care remains a cost-effective strategy for states unless it results in a two-order-of-magnitude lesser reduction in these outcomes, a less than 0.002% decrease in infant mortality or less than 0.001% decrease in extremely low birthweight infants. Prenatal care remained a cost-effective strategy for Medicaid when other variables were ranged from one-half to twice the base estimate. The same finding was observed for the lifetime medical costs of a child with moderate to severe disabilities (Figure 2). As the costs of neonatal and infant care increase, prenatal care becomes even more cost effective. We examined the costs of lifetime medical care for a child with disabilities to determine if a threshold value exists, whereby it would be cost saving rather than cost effective for the state to cover prenatal care. If the lifetime costs of medical care exceed $2.4 million, then prenatal care would become cost saving, not just cost effective.
      Figure thumbnail gr2
      Figure 2One-way sensitivity analysis on lifetime medical costs for a child with moderate to severe disability associated with cerebral palsy. Costs are presented in dollars and inflated for 2018. Prenatal care was cost effective at a willingness-to-pay threshold of $100,000.
      A Monte Carlo simulation of 10,000 trials was performed to further assess the robustness of the model. At a willingness-to-pay threshold of $100,000 per QALY, prenatal care coverage was cost effective in 99% of strategies, regardless of how model inputs were varied across distributions (Figure 3).
      Figure thumbnail gr3
      Figure 3Costs are in dollars and inflated for 2018. Outcomes of 10,000 trials from Monte Carlo simulation. Each dot represents single trial outcome. Ellipse marks 95% confidence interval. Dashed line represents willingness-to-pay threshold of $100,000; all dots below threshold represent prenatal coverage as cost-effective.

      Discussion

      We found that offering prenatal care health insurance coverage to low-income unauthorized immigrants and recently arrived legal permanent residents is cost effective. Amid national political debate regarding public services offered to noncitizens and specifically unauthorized immigrants, this study suggests that restricting access to prenatal care results in negative health consequences for women and their offspring and expanding coverage is an efficient use of Medicaid funds.
      From 2008 to 2013, Oregon introduced covered prenatal care for the Emergency Medicaid population in a stepwise fashion to all 36 counties. We have reported the effects of this policy previously (
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Expanding prenatal care to unauthorized immigrant women and the effects on infant health.
      ,
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Oregon’s expansion of prenatal care improved utilization among immigrant women.
      ). Access to prenatal care was associated with improved health care use for women and their children, more frequent diagnoses of key high-risk conditions, and improved uptake of preventive care (
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Expanding prenatal care to unauthorized immigrant women and the effects on infant health.
      ,
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Oregon’s expansion of prenatal care improved utilization among immigrant women.
      ). We also found a significant decrease in the likelihood of infant death in the first year of life and extremely low birthweight associated with maternal access to care (
      • Swartz J.J.
      • Hainmueller J.
      • Lawrence D.
      • Rodriguez M.I.
      Expanding prenatal care to unauthorized immigrant women and the effects on infant health.
      ). The current study demonstrates that access to prenatal care is also cost effective for this population.
      Our study is not without limitations. As with all cost-effectiveness analyses, our estimates are limited by the assumptions inherent to the model. We performed a sensitivity analysis widely around all variables to address this limitation. For example, we closely scrutinized health care use and costs, which may vary over time and by state. Prenatal care coverage for unauthorized immigrants is funded primarily through CHIP or the Children's Health Insurance Program Reauthorization Act. Both programs have state and federal contributions and, because the federal matching percentage varies by state, we do not estimate specific state contributions. Moreover, consideration of the effects of global or bundled payment models were out of the scope of this analysis. Additionally, safety net clinics are a potential source of prenatal care for unauthorized immigrants. Resources available in each state vary, and it is not known to what extent these offset the restrictions under Emergency Medicaid for this population.
      Oregon's health care and policy environment may not be generalizable to all other states. For example, as noted elsewhere in this article, uptake might be lower in areas where fear regarding immigration status enforcement is greater, and that factor could lower the effectiveness of coverage policies. Because it is outside the scope of this analysis, we also did not model the cost effectiveness of extending prenatal care if it led to a change in fertility rates. We did use sensitivity analysis to examine the controversial question of the Latina or immigrant paradox. For many years, a body of evidence suggested that immigrant women, despite social disadvantage, were more likely to have healthier birth outcomes than their U.S.-born counterparts (
      • Almeida J.
      • Mulready-Ward C.
      • Bettegowda V.R.
      • Ahluwalia I.B.
      Racial/ethnic and nativity differences in birth outcomes among mothers in New York City: The role of social ties and social support.
      ,
      • Brown H.L.
      • Chireau M.V.
      • Jallah Y.
      • Howard D.
      The “Hispanic paradox”: An investigation of racial disparity in pregnancy outcomes at a tertiary care medical center.
      ,
      • Cervantes A.
      • Keith L.
      • Wyshak G.
      Adverse birth outcomes among native-born and immigrant women: Replicating national evidence regarding Mexicans at the local level.
      ,
      • Gagnon A.J.
      • Zimbeck M.
      • Zeitlin J.
      • ROAM Collaboration
      • Alexander S.
      • Blondel B.
      • Zimbeck M.
      Migration to western industrialised countries and perinatal health: A systematic review.
      ). Not all research has supported this assertion, however. Many studies that adjust for socioeconomic characteristics and stratify by subgroups of Latinas have found the opposite: immigrant Latinas had a higher likelihood of adverse birth outcomes than non-Hispanic White women (
      • Sanchez-Vaznaugh E.V.
      • Braveman P.A.
      • Egerter S.
      • Marchi K.S.
      • Heck K.
      • Curtis M.
      Latina birth outcomes in California: Not so paradoxical.
      ). We ranged the probability of a high-risk pregnancy and associated adverse perinatal outcomes broadly to identify how changes in the population composition would impact results. Regardless of the proportion of women having a high-risk pregnancy, prenatal care coverage was cost effective. As the probability of a high-risk pregnancy increased, prenatal care remained cost effective and eventually became a cost-saving strategy.

      Implications for Practice and/or Policy

      Our findings have policy and health implications. We find that restricting access to prenatal care by immigration status was associated with increased costs. These data suggest that states could expand their scope of care using an already available and cost-effective provision of CHIP associated with multigenerational positive health effects.
      The national context for expansion of services, however, is being rapidly redefined by the Trump administration. Changes in national immigration policy and the surrounding national dialogue have created a chilling effect impacting health care use during pregnancy among Latina women (citizens and immigrants) (
      • Gemmill A.
      • Catalano R.
      • Casey J.A.
      • Karasek D.
      • Alcalá H.E.
      • Elser H.
      • Torres J.M.
      Association of preterm births among US Latina women with the 2016 presidential election.
      ). New rules from the Department of Homeland Security, which took effect in February 2020, may deter unauthorized and authorized immigrant participation in publicly funded aid programs (
      Kaiser Family Foundation
      Changes to “Public Charge” inadmissibility rule: Implications for health and health coverage. The Henry J. Kaiser Family Foundation, Disparities Policy.
      ,
      • Kraft C.
      • Hollier L.
      • Lopez A.M.
      279,000 Physicians: Public Charge Proposal is a Threat to Our Patients’ Health | Opinion. Newsweek.
      ,
      • Perreira K.M.
      • Yoshikawa H.
      • Oberlander J.
      A new threat to immigrants’ health—The Public-Charge rule.
      ,
      • Immigrant Legal Resource Center (ILRC)
      Public Charge.
      ). The rule has redefined recipients of public assistance like Medicaid or Supplemental Nutrition Assistance Program as “public charges,” and uses this classification to adversely influence applications for immigration status changes or extensions (
      • Perreira K.M.
      • Yoshikawa H.
      • Oberlander J.
      A new threat to immigrants’ health—The Public-Charge rule.
      ,
      • Immigrant Legal Resource Center (ILRC)
      Public Charge.
      ). Although this rule exempts those under 21 and pregnant women, public health advocates remained concerned (
      Kaiser Family Foundation
      Changes to “Public Charge” inadmissibility rule: Implications for health and health coverage. The Henry J. Kaiser Family Foundation, Disparities Policy.
      ). The rule may create additional barriers to uptake of care, both in states with expanded coverage and those considering expansion through CHIP funding. Restricting access to care based on immigration status may also have collateral implications for U.S. citizens. Laws requiring strict proof of U.S. citizenship have been shown in prior studies to delay prenatal care for U.S. citizens and thereby increase public costs (
      • Angus L.
      • DeVoe J.
      Evidence that the citizenship mandate curtailed participation in Oregon’s Medicaid family planning program.
      ,
      • Rodriguez M.I.
      • Angus L.
      • Elman E.
      • Darney P.D.
      • Caughey A.B.
      Financial effect of instituting Deficit Reduction Act documentation requirements in family planning clinics in Oregon.
      ).
      Future research on the impact of health care coverage during pregnancy should focus on how care during different time points (prenatal, postpartum, interconceptual care) impacts maternal and neonatal health, as well as public costs. Health risks for the woman and the newborn extend beyond the delivery and through the first months postpartum (
      • McKinney J.
      • Keyser L.
      • Clinton S.
      • Pagliano C.
      ACOG Committee Opinion No. 736: Optimizing postpartum care.
      ). Even in the minority of states that do provide prenatal care coverage for unauthorized immigrants, coverage ends the day a woman gives birth. Oregon is one of a few states that explicitly provides postpartum coverage for all women, regardless of citizenship status. Oregon's Reproductive Health Equity Act provides comprehensive postpartum care, including the option of immediate postpartum long-acting reversible contraceptives (
      Oregon Health Authority
      General Rules Administrative Rulebook. Oregon Health Authority, Health Systems Division Integrated Health Programs.
      ). Understanding how care during different periods in pregnancy and the puerperium influences maternal and neonatal health, as well as public costs, is needed to inform policy.

      Conclusions

      To improve maternal and child health in the United States, attention is needed to address structural factors that shape health and opportunity. Health care coverage during pregnancy influences the well-being of the current and next generation. Evidence-based policy that optimizes health equitably while rationally using public funds can contribute to this goal.

      Supplementary Data

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      Biography

      Maria I. Rodriguez, MD, MPH, is Associate Professor, Section of Family Planning, Department of Obstetrics and Gynecology, Oregon Health & Science University.
      Jonas J. Swartz, MD, MPH, is Assistant Professor, Division of Women's Community and Population Health, Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina.
      Duncan Lawrence, PhD, MA, is Executive Director, Immigration Policy Lab, Stanford University.
      Aaron B. Caughey, MD, MPP, MPH, PhD, is Professor and Chair, Associate Dean for Women's Health Research & Policy, Department of Obstetrics and Gynecology, Oregon Health & Science University.