The Effect of Providing Health Coverage to Poor Uninsured Pregnant Women in Massachusetts

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Abstract
Objectives. —There has been substantial policy interest in whether the provision of health coverage to poor uninsured pregnant women affects access to prenatal care and birth outcomes. We therefore examined whether the statewide provision of health coverage to uninsured low-income pregnant women affects access to prenatal care and infant birth outcomes. Design. —Natural experiment. Patients. —All inhospital, single-gestation live births in 1984 (N=57257) and 1987 (N=64 346). Intervention. —In 1985, Massachusetts instituted Healthy Start, a program providing health coverage to uninsured pregnant women with incomes below 185% of the federal poverty level. Main Outcome Measures. —Rates of satisfactory prenatal care, care initiated before the third trimester, and adverse infant outcome for uninsured women and for two concurrent control groups, women with Medicaid, and women with private insurance. We calculated the difference in rates between the uninsured and each concurrent control. To assess the effect of the program, we examined the change in these interpayer differences in rates between 1984 and 1987. Main Results. —Between 1984 and 1987, the rate of satisfactory prenatal care declined from 96.4% to 93.8% for all women in Massachusetts (P<.001). There was no statewide change in the overall incidence of adverse birth outcome (6.6% in both years). In 1984, uninsured women were less likely than privately insured women to receive satisfactory prenatal care (90.5% and 98.1%, respectively; interpayer difference, -7.6%) and to initiate care before the third trimester (94.2% and 99.1%; interpayer difference, -4.9%), and were more likely to suffer an adverse birth outcome (7.1% and 5.8%; interpayer difference, 1.3%). Between 1984 and 1987, there were no statistically significant changes in the interpayer differences in rates for any of the outcome measures relative to either control group. Conclusions. —Our findings suggest that access to prenatal care may have declined for all women in Massachusetts between 1984 and 1987. In the setting of this statewide decline in access, the expansion of health coverage to uninsured low-income pregnant women was not associated with an improvement in access to prenatal care or birth outcomes. (JAMA. 1993;269:87-91)

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