Three Essays on Policies Affecting Women’s and Infants’ Health in the U.S. Público
Strahan, Andrea (Summer 2018)
Abstract
Under federalism in the U.S., state and federal governments share power. States can customize health policies within federal standards, acting as laboratories for health policy innovation in pursuit of improved access, utilization, and outcomes. This dissertation focuses on three policies that exist at the intersection of state and national policy to examine how they impact women’s and infants’ health.
In Chapter One, I investigate if the Affordable Care Act (ACA) dependent coverage provision has affected unintended pregnancy and related prenatal behaviors among young adult mothers. This policy began at the state level and was implemented nationally with the 2010 health reform law. I find the ACA provision is associated with important gains in preconception private insurance for young adult women and declines in smoking during pregnancy, but not with changes to unintended pregnancy.
In Chapter Two, I examine whether variation over time in state scope of practice laws for Certified Nurse-Midwives has affected infant mortality from 1994-2014. Results show that changes in these laws do not impact infant deaths, indicating that allowing Certified Nurse-Midwives to practice without regulatory barriers does not pose a threat to public health in terms of infant mortality. This finding has important implications for access to healthcare in states facing provider shortages.
In Chapter Three, I test the effects of state Medicaid policies on early-term elective deliveries (EEDs) and infant health outcomes. Such Medicaid policies vary widely by state and have gained popularity in recent years due to growing awareness of the increased risks to infants born between 37 and <39 weeks gestation. I find that state policies denying reimbursement for non-medically indicated early-term inductions and cesarean sections are associated with a reduction in EEDs, but also an increase in full-term elective cesarean sections and no changes in infant health.
Together, this research provides new estimates of policies affecting women’s and infants’ health in the U.S. These findings can inform future policy innovation at the state and national level concerning extensions of dependent coverage, potential solutions to physician shortages, and Medicaid reimbursement policies around childbirth.
Table of Contents
Chapter 1. Association of the Affordable Care Act Dependent Coverage Provision with
Unintended Pregnancy and Prenatal Behaviors
a. Introduction………………………………………………………………..1
b. Background………………………………………………………………..3
c. Conceptual Framework…………………………………………………....5
d. Study Design……………………………………………………………....7
e. Results……………………………………………………………………14
f. Discussion……………………………………………………..…………15
g. Tables & Figures…………………………………………………………19
Chapter 2. Scope of Practice Laws and Certified Nurse-Midwives: Effects of Changing
Regulatory Environments on Infant Mortality
a. Introduction………………………………………………………………23
b. Background………………………………………………………………27
c. Conceptual Framework…………………..………………………………29
d. Study Design………………………………..……………………………31
e. Results……………………………………………………………………35
f. Discussion……………………………………..…………………………37
g. Tables & Figures…………………………………………………………40
Chapter 3: The Impact of Medicaid Policies on Early Elective Deliveries and Infant Health
a. Introduction………………………………………………………………46
b. Background………………………………………………………………48
c. Conceptual Framework………………………………..…………………52
d. Study Design……………………………………………..………………55
e. Results……………………………………………………………………61
f. Discussion…………………………………………………..……………63
g. Tables & Figures…………………………………………………………66
References…………………………………………………...…………………………..72
Appendix A: Chapter 1 Supplementary Materials..…………..…….………………..86
Appendix B: Chapter 2 Supplementary Materials....…………………….…………..91
Appendix C: Chapter 3 Supplementary Materials …………………………...……...98
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