title: The impact of welfare reform on insurance coverage before pregnancy and the timing of prenatal care initiation.
abstract: OBJECTIVE
  This study investigates the impact of welfare reform on insurance coverage before pregnancy and on first-trimester initiation of prenatal care (PNC) among pregnant women eligible for Medicaid under welfare-related eligibility criteria.
  
  
  METHODS
  We used pooled data from the Pregnancy Risk Assessment Monitoring System for eight states (AL, FL, ME, NY, OK, SC, WA, and WV) from 1996 through 1999.
  
  
  METHODS
  We estimated a two-part logistic model of insurance coverage before pregnancy and first-trimester PNC initiation. The impact of welfare reform on insurance coverage before pregnancy was measured by marginal effects computed from coefficients of an interaction term for the postreform period and welfare-related eligibility and on PNC initiation by the same interaction term and the coefficients of insurance coverage adjusted for potential simultaneous equation bias. We compared the estimates from this model with results from simple logistic, ordinary least squares, and two-stage least squares models.
  
  
  RESULTS
  Welfare reform had a significant negative impact on Medicaid coverage before pregnancy among welfare-related Medicaid eligibles. This drop resulted in a small decline in their first-trimester PNC initiation. Enrollment in Medicaid before pregnancy was independent of the decision to initiate PNC, and estimates of the effect of a reduction in Medicaid coverage before pregnancy on PNC initiation were consistent over the single- and two-stage models. Effects of private coverage were mixed. Welfare reform had no impact on first-trimester PNC beyond that from reduced Medicaid coverage in the pooled regression but separate state-specific regressions suggest additional effects from time and income constraints induced by welfare reform may have occurred in some states.
  
  
  CONCLUSIONS
  Welfare reform had significant adverse effects on insurance coverage and first-trimester PNC initiation among our nation's poorest women of childbearing age. Improved outreach and insurance options for these women are needed to meet national health goals.
authors.affiliation: RTI International, 3040 Cornwallis Road, P.O. Box 12194, Research Triangle Park, NC 27709-2194, USA.
authors.forename: Norma I
authors.initials: NI
authors.lastname: Gavin
authors.forename: E Kathleen
authors.initials: EK
authors.lastname: Adams
authors.forename: Willard G
authors.initials: WG
authors.lastname: Manning
authors.forename: Cheryl
authors.initials: C
authors.lastname: Raskind-Hood
authors.forename: Matthew
authors.initials: M
authors.lastname: Urato
mesh_terms: D005260:Female; D006297:Health Services Accessibility / Q000458:organization & administration / Q000706:statistics & numerical data; D006801:Humans; D019458:Insurance Coverage / Q000458:organization & administration / Q000706:statistics & numerical data*; D007348:Insurance, Health / Q000706:statistics & numerical data*; D008484:Medicaid / Q000458:organization & administration / Q000706:statistics & numerical data; D011247:Pregnancy; D011261:Pregnancy Trimester, First; D011295:Prenatal Care / Q000706:statistics & numerical data*; D011632:Public Assistance / Q000458:organization & administration* / Q000706:statistics & numerical data*; D012959:Socioeconomic Factors; D013997:Time Factors; D014481:United States