Amy M. Wolaver Bucknell University Health Economics Interest Group Meeting, ARM June 7, 2008

1. The Efficacy of Medicaid Family Planning Waivers On Young Women: Difference-in-Difference Evidence from National Microdata Amy M. Wolaver Bucknell University Health Economics Interest Group Meeting, ARM June 7, 2008

2. Alternative Views on Contraception • When the history of civilization is written, it will be a biological history and Margaret Sanger will be its heroine." •  H.G. Wells • Chastity: The most unnatural of the sexual perversions. • Aldous Huxley • For most women, including women who want to have children, contraception is not an option; it is a basic health care necessity. • Louise Slaughter • You must strive to multiply bread so that it suffices for the tables of mankind, and not rather favor an artificial control of birth, which would be irrational, in order to diminish the number of guests at the banquet of life. • POPE PAUL VI, speech, Oct. 4, 1965 • The best contraceptive is the word no - repeated frequently.  • Margaret Smith • The best contraceptive is a glass of cold water:  not before or after, but instead.  • Author Unknown

3. Introduction • Half of pregnancies in US are unintended (Guttmacher Institute) • Teen pregnancy has fallen in US but remains higher than other countries • Problems with teen childbearing • Public costs (Medicaid, welfare, education) • Health of mother & infant (low birthweight, premature birth etc…)

4. Family Planning Coverage for Poor Women • Medicaid accounts for over ½ of Federal funds for contraceptive services • More than Title X funds • Copays are prohibited • Federal matching rate more generous than for other Medicaid services

5. Medicaid Section 1115 Family Planning Waivers • Provides limited (contraceptive, STD testing, counseling) benefits to additional persons not on regular Medicaid • Must be budget neutral (to Medicaid) over 5 year period • 90% federal matching rate for BC • Higher than other services • Justification: reduces more costly, but lower-matched Medicaid births • Additional public savings from related avoided costs

6. Political Considerations • Most estimates find FP waivers cost-neutral or saving from federal perspectives • Attractive to states because of generous match rate • Public funding of contraception remains controversial • Encourages teen sex? • Unintended consequences? • Religious objections to any contraception

7. Waiver History • Two strategies: • Extending FP services after regular (post-partum) Medicaid loss: 1994 Rhode Island & SC post-partum extension • Raise Income cut-off for FP services: California PACT 1997 • As of 2/1/08 Twenty-seven states have implemented • Variation in timing, eligibility rules, coverage of teens/males

8. Previous Research on Public Contraceptive Coverage • May increase provider availability (Frost et al. 2004) • Increases use, more effective BC methods (Forrest & Samara 1996) • Inattention to endogeneity may lead to underestimates of policy efficacy (Mellor 1998) • Income-related waivers reduce state birth rates (Lindrooth & McCullough 2007)

9. Methods • Difference-in-difference-in-difference • Create treatment group (eligible/would be eligible) based on waiver rules in policy & matched states • Two control groups: Medicaid eligible, ineligible for both FP & regular Medicaid

10. Methods, continued • Stage 1: Difference-in-difference (DD) • Compare pre- & post-waiver outcomes of treatment & control groups within waiver states (DD1) • Repeat with treatment & control in matched/comparison states (DD2) • Stage 2: Difference-in-difference-in-difference (DDD) • Compare first stage results = DD1-DD2

11. Regression Framework • Because data are panel • same women in pre- & post-, tx & control groups; • policy variation also occurring as cohort ages, experiences life cycle fertility changes

12. Regression Framework, cont’d • OLS & Fixed effects • Also includes time & state dummies • Individual fixed effects • Includes controls for age, menses y/n, Medicaid eligible, urban • Linear probability models • Fixed effects complex in nonlinear models, can introduce biases (Greene 2004) • Interaction effects even more complex in nonlinear models (Ai & Norton 2003) • But, heteroskedasticity, predictions outside 0/1 bounds • Use LPM, correct standard errors for heteroskedasticity, check against WLS estimates

13. Data • 1997 National Longitudinal Survey of Youth • Women aged 12-18 in 1997 • Annual waves available from 1997-2005 • Only women 14 or older • Policy information from Guttmacher Institute, cross checked with CMS

14. Outcomes • Childbearing • Pregnant since last interview • Gave birth since last interview • Pregnant w/out live birth (abortion, miscarriages & still births combined) since last interview • Contraceptive use • At last intercourse • Typical pregnancy risk w/ usual BC method • Percent of time use BC • Sexually active since last interview

15. Policy Variation

16. Waiver/Comparison States Characteristics

17. DDD Results Source: Author’s calculations from 1997 NLSY. Regressions also control for state, sample year, age, menses, Medicaid eligibility, and urbanicity. Standard errors corrected for clustering at individual level. *, † Statistically significant at the 1%, 5% level. a. Standard errors corrected for heteroskedasticity in linear probability models.

18. DDD Results, cont’d Source: Author’s calculations from 1997 NLSY. Regressions also control for state, sample year, age, menses, Medicaid eligibility, and urbanicity. Standard errors corrected for clustering at individual level. *, † Statistically significant at the 1%, 5% level. a. Standard errors corrected for heteroskedasticity in linear probability models.

19. DDD Results, cont’d Source: Author’s calculations from 1997 NLSY. Regressions also control for state, sample year, age, menses, Medicaid eligibility, and urbanicity. Standard errors corrected for clustering at individual level. *, † Statistically significant at the 1%, 5% level. a. Standard errors corrected for heteroskedasticity in linear probability models.

20. General Results • Decreases sexual activity • Decreases probability of pregnancy, giving birth, & combined abortion, miscarriages & stillbirth • Large, statistically significant effects • Greater relative impact on combined abortion, miscarriages & stillbirth than on giving birth • Extension waivers have larger impact • No measured impact on contraceptive outcomes

21. Robustness Checks • Dropping pre-1997 waiver states • Income eligibility waivers have negative, statistically significant impact on pregnancy & giving birth • Extension waivers impact same magnitude except in FE (drops to match OLS results) • Dropping nonwhites increases estimates of efficacy • Separate examination compared to Medicaid eligible, other control group • More effective relative to Medicaid eligible control, stronger impacts • FE similar to OLS, except for extension waivers • WLS estimates slightly smaller than OLS/FE

22. Teens • No statistically significant impact on sexual activity • Any-type waiver decreases teen pregnancy, motherhood, combined abortion, miscarriage & still births • Income eligibility waivers decrease pregnancy, teen mother hood • Extension waivers decrease teen pregnancy

23. Rural/Urban Differences

24. Future Directions • BC consistency of use sensitive to outliers? • More work on unplanned/unwanted pregnancy • Other pregnancy outcomes (spacing, prenatal care, low birth weight / premature birth) • Males • Other aspects of policy (enrollment practices etc…) • Older women • Other reproductive health policies, provider availability (addition of Guttmacher Institute data) • Cost-benefit ratios

25. Conclusions • Effective at reducing pregnancies, combined abortions, miscarriages & stillbirths, bigger effects for teens • No increased sexual activity • Results apply to all eligible young women, not just participants • Robust to sampling assumptions • DDD + fixed effects provide strong support for waivers