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Ted Joyce, PhD, Tamar Bauer, JD, Howard Minkoff, MD and Robert Kaestner, PhD

At the time of the study, Ted Joyce and Robert Kaestner were with Baruch College, City University of New York, and the National Bureau of Economic Research, New York, NY. Tamar Bauer is with the New York Academy of Medicine, New York, NY. Howard Minkoff is with Maimonides Medical Center, Brooklyn, NY, and the State University of New York Health Science Center at Brooklyn.

Correspondence: Requests for reprints should be sent to Ted Joyce, PhD, National Bureau of Economic Research, 365 Fifth Ave, 5th Floor, New York, NY 10016–4309 (e-mail: ted_joyce{at}baruch.cuny.edu).

	ABSTRACT

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION References

 

Objectives. This study analyzed changes in the financing of prenatal care and delivery, the use of prenatal care, and birth outcomes among foreign-born vs US-born Latino women following enactment of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) in August 1996.

Methods. We used a pre–post design with a comparison group. The sample consisted of resident Latinas in California, New York City, and Texas who delivered a live infant in 1995 or 1998.

Results. The proportion of births to Latinas that initiated prenatal care in the first 4 months of pregnancy increased for all foreign-born Latinas in California, New York City, and Texas between 1995 and 1998 (P < .05). Except for non-Dominicans in New York City, there was no increase in the proportion of low- or very-low-birthweight births among foreign-born vs US-born Latinas in the 3 localities between 1995 and 1996.

Conclusions. There is little evidence from vital statistics in California, New York City, and Texas that PRWORA had any substantive impact on the perinatal health and health care utilization of foreign-born relative to US-born Latinas.

	INTRODUCTION

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION References

 
The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 fundamentally altered federal law regarding immigrant eligibility for Medicaid and other public benefits to immigrants. All legal immigrants entering the country after August 22, 1996, except those in protected categories that include refugees and asylum seekers, were barred from receiving federal public benefits for at least 5 years. As a result, many immigrants became ineligible for Medicaid coverage of prenatal care. In states like California, New York, and Texas, the number of immigrants potentially affected by this bar was significant. In 1995, 44% of all births in California, 43% of all births in New York City, and 25% of all births in Texas were to foreign-born women. In California and New York City, over 60% of births to foreign-born women were financed by Medicaid (authors' tabulations, available from the corresponding author).

Since states responded differently to the new withdrawal of federal eligibility and funds, immigrants' perceived and actual loss of eligibility varied by state. For example, California chose to use state funds to finance the prenatal care of immigrants who were newly ineligible for federally funded Medicaid; in addition, California continued to use state funds for prenatal care for the undocumented. New York opted not to provide Medicaid to immigrants who entered the United States after August 1996. However, owing to a long-standing federal court decision,¹ Medicaid eligibility for all pregnant women in New York remained intact, regardless of their immigration status. On February 27, 1997, the federal government filed a motion to vacate this order, but it was denied in district court on January 19, 2000.

In Texas, unlike in California, elected officials chose not to use state funds to replace the funds withdrawn by the federal government for prenatal care of Medicaid-eligible immigrants. This decision was implemented only 1 month after the passage of PRWORA (Texas Department of Human Services, unpublished data, 1996).

The fear and confusion in the immigrant communities engendered by PRWORA has been widely reported, although the behavioral consequences of that concern have not been assessed.^2–6 A study by researchers at the Urban Institute reported large drops in Medicaid coverage among immigrants in Los Angeles County in the wake of welfare reform despite there being no change in their eligibility and no similar decline among citizens.⁷ In New York City, there have also been reports of a substantial increase in the number of women who were awarded, but did not collect, food coupons under the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in neighborhoods with large numbers of births to foreign-born women.⁸ Finally, focus groups in California, New York, and Texas indicate that extensive misinformation and confusion exists.^9,10

How much of the decline in the use of public benefits documented in these reports represents statewide trends is unclear. Moreover, there are few data to demonstrate adverse clinical outcomes among communities most likely to perceive or experience a change in access to primary care following federal or state initiatives. We therefore undertook this study to discern the effect of the new law on the perinatal health and health care utilization of Latino women. If welfare reform makes foreign-born women ineligible for, or fearful of seeking, publicly provided health insurance, then we may observe an increase in the percentage of births to foreign-born women that are uninsured, a decrease in early initiation of prenatal care, and an increase in adverse birth outcomes. To test this hypothesis, we used birth certificates from California, New York City, and Texas to characterize changes in perinatal outcomes among foreign-born vs US-born Latinas between 1995 and 1998. Specifically, we compared changes in the financing of births (Medicaid and self-pay), prenatal care utilization (early initiation of care and prenatal visits), and birth outcomes (low birthweight, very low birthweight, and preterm delivery) between US-born and foreign-born Latinas from 1995 to 1998.

	METHODS

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Data
We used birth files from California, New York City, and Texas. We focused on Latinas for several reasons. First, births to Latinas constitute the largest proportion of births to foreign-born women in California, New York City, and Texas; in 1995, over 71% of all births to foreign-born women in California, 45% in New York City, and 81% in Texas were to women from Latin American countries. Second, 65% of all births to Latinas in California and 74% in New York City, regardless of nativity, were financed by Medicaid (authors' tabulations, available from the corresponding author). Thus, Latinas were particularly vulnerable to the potential withdrawal of benefits under PRWORA or to confusion regarding eligibility. Third, there was a relatively large number of births to US-born Latinas in California, New York City, and Texas. These women were US citizens and, unlike many immigrants, did not become ineligible for Medicaid under the terms of PRWORA. Thus, US-born Latinas constitute a natural comparison group with which to analyze the effects of PRWORA on the perinatal health and behavior of their foreign-born counterparts.

We examined changes in outcomes in 3 areas related to the health and health care of pregnant immigrants and their newborns that may be affected by welfare reform. First, we analyzed how the birth was financed. In New York City, method of finance refers to delivery. In California, method of finance is recorded separately for prenatal care and delivery. We used the method of finance for prenatal care in California; however, insurance status rarely differed between the 2 periods. We classified as uninsured women whose method of finance was listed as self-pay. Second, we looked at changes in the proportion of births to women who began care in the first 4 months of pregnancy as well as the number of prenatal care visits. Loss of Medicaid eligibility as well as confusion and fear of scrutiny may have caused immigrants to initiate prenatal care later than they would have in the absence of PRWORA. Finally, we analyzed changes in the proportion of low-birthweight births, very-low-birthweight births, and preterm births before and after PRWORA.

We first constructed time series of perinatal outcomes for all singleton births to US- and foreign-born Latino residents of California, New York City, and Texas between 1989 and 1998. We then analyzed more detailed breakdowns by ethnicity. In California and Texas, the largest group of Latinas were Mexican. We grouped all other Latinas together. Thus, we compared US-born Mexicans with foreign-born Mexicans and all other US-born Latinas with foreign-born Latinas. In New York City, Dominicans constituted the largest group of Latinas after Puerto Ricans. Again, all other Latinas were grouped together. Comparisons in New York City, therefore, were between US-born and foreign-born Dominicans and between all other US-born and foreign-born Latinas. We excluded Puerto Ricans from all analyses since, although they are Latino, they were all born in the United States.

Statistical Methods
We used 1995 as the pre-PRWORA period and 1998 as the post-PRWORA period. (PRWORA was signed into law on August 16, 1996.) In bivariate comparisons, we used z statistics to test differences in outcomes before and after PRWORA. Although most outcomes were dichotomous, we assumed that differences followed a normal distribution, given the large number of observations in our samples. In multivariate analyses, we used logistic regression for dichotomous dependent variables. We adjusted for maternal age, marital status, completed schooling, parity, infant sex (in birth outcome models only), year, nativity, and ethnicity.

	RESULTS

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Time Series
Figure 1 shows the annual percentage of births between 1989 and 1998 to all Latino women in California and New York City who were uninsured during prenatal care (California) or at delivery (New York City). We present separate time series for US-born and foreign-born Latinas. Two observations are noteworthy. First, there was a rapid decline between 1989 and 1991 in the proportion of births to foreign-born Latino women who were uninsured during prenatal care in California and at delivery in New York City. US-born Latinas experienced notable but lesser declines. The fall is probably related to the expansion in the income eligibility thresholds for Medicaid.^11,12 Second, there was little evidence of an increase in births between 1995 and 1998 to women who were uninsured in the prenatal period in California or at delivery in New York City.

View larger version (23K): [in this window] [in a new window]   FIGURE 1— —Percentage of births to uninsured US-born and foreign-born Latino women: California and New York City, 1989–1998.

View larger version (27K): [in this window] [in a new window]   FIGURE 2— —Percentage of early prenatal care among US-born and foreign-born Latino women: California, New York City, and Texas, 1989–1998.

View larger version (24K): [in this window] [in a new window]   FIGURE 3— —Percentage of low-birthweight births to US-born and foreign-born Latino women: California, New York City, and Texas, 1989–1998.

Changes in perinatal outcomes among Dominicans and other Latinas in New York City are presented in Table 2. Changes among Dominicans paralleled those for Mexicans in California. Importantly, we found an increase of 7.8 percentage points in early initiation of prenatal care among foreign-born Dominicans that exceeded the 5.2-percentage-point rise among US-born Dominicans. The only anomaly is the significant rise in preterm births among foreign-born Dominicans and other Latinas between 1995 and 1998. However, the largest increase occurred among births to other Latinas born in the United States. Moreover, the rise in preterm births was unaccompanied by any significant change in the percentage of low- or very-low-birthweight births.

Results for Texas are displayed in Table 3. We present outcomes for prenatal care and birth outcomes because the birth certificate in Texas does not include method of finance. The pattern of change in Texas was similar to that of California and New York City. Early initiation of prenatal care increased by 2.9 percentage points among foreign-born Mexicans, compared with 1.8 percentage points among US-born Mexicans. There was no change in low or very low birthweight. Changes in outcomes among other Latinas in Texas were similar. As in New York City, there was a rise in the percentage of preterm births that was greatest among US-born, non-Mexican Latinas.

Multivariate Analyses
Table 4 shows adjusted odds ratios for changes in perinatal outcomes among foreign-born vs US-born Latinas in our 3 localities. We limited the outcomes to lack of insurance, early prenatal care, and low birthweight. Among Mexicans in California, the odds that a woman was uninsured in the prenatal period increased 9% more among foreign-born women than among US-born women between 1995 and 1998 (95% confidence interval [CI] = 1.01, 1.19). There was not a similar increase among other Latinas. Despite the relative increase in lack of insurance, the odds that a Mexican woman initiated prenatal care in the first 4 months of pregnancy increased more among foreign-born than among US-born Mexicans between 1995 and 1998 (odds ratio [OR] = 1.11; 95% CI = 1.06, 1.15). Finally, there was no differential increase in the percentage of low- or very-low-birthweight births among foreign-born vs US-born Latinas in California.

	DISCUSSION

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION References

 
We found little evidence that welfare reform altered the financing of prenatal care and delivery among foreign-born Latinas in California and New York City or access to prenatal care in California, New York City, or Texas. On the contrary, we report gains in the early initiation of prenatal care and the number of prenatal visits among foreign-born Latinas compared with US-born Latinas. The latter finding was unexpected. Many argued that PRWORA would diminish access to primary care among foreign-born women directly—by the cutoff of funding—and indirectly by engendering fear and confusion (Texas Department of Human Services, unpublished data, 1996).^3,13–15 Even in Texas, where state officials moved swiftly to end financial support for prenatal care among immigrants unqualified for Medicaid under PRWORA, we found gains in prenatal care among foreign-born Latinas. The gains in Texas were noteworthy because they were similar to those in California and New York City, where state funds for prenatal care were used to replace federal monies lost under PRWORA.

There were some anomalies. The percentage of preterm births rose among subgroups of Latinas in each of the 3 localities for which we had data. The increase, however, was often observed for US-born as well as foreign-born Latinas. Moreover, the increase was not corroborated by an increase in low and very low birthweight or a fall in early initiation of prenatal care. We doubt, therefore, that the rise was attributable to welfare reform. We also found a statistically significant increase in the odds of low-birthweight birth among foreign-born relative to US-born non-Dominican Latinas in New York City. Again, we are skeptical that the increase was attributable to PRWORA because the increased odds ratio resulted from a large fall in the incidence of low birthweight among other Latinas born in the United States as opposed to a statistically significant increase in the percentage of low-birthweight births among foreign-born women.

The third anomaly pertained to the fall in the percentage of births in which prenatal care was financed by Medicaid in California. We speculate that because of the growth in Medicaid managed care, women described their insurance provider as a health maintenance organization (HMO) instead of California's Medicaid program (Medi-Cal). Data from 2 other sources are consistent with this interpretation. On the basis of Medi-Cal claims data and estimates of Medicaid-financed deliveries to women in prepaid health plans, the California Department of Health reported 229 158 deliveries financed by Medi-Cal in 1995 and 209 268 in 1998. This represents 41.6% and 40.1% of all resident births in 1995 and 1998, respectively. Importantly, however, the number of deliveries financed by Medi-Cal to women in prepaid health plans rose from 18 800 in 1995 to 64 400 in 1998.^16,17 The other source of data—the National Governors' Association annual survey of state Medicaid agencies—reported that 42% and 43% of all deliveries in California were financed by Medicaid in 1995 and 1997, respectively.^18,19 Finally, the more relevant finding regarding the financing of prenatal care and delivery is the lack of any substantive change in the percentage of uninsured associated with welfare reform in either California or New York City.

Several caveats related to the data should be noted. First, our data are repeat cross sections of births and not a panel of women followed over time. Thus, despite a lack of change in the percentage of uninsured at the aggregate level, we do not know who among foreign-born and US-born women gained or lost health insurance coverage related to pregnancy between 1995 and 1998. Second, we have data only through 1998 and thus were able to analyze only the initial impact of PRWORA. However, the fear and uncertainty surrounding PRWORA may have been greater in 1997 and 1998 than more recently, especially in California (see below); thus, any effect associated with the "chilling" impact of welfare reform among immigrants would most likely have been observed during our study period. Third, the Texas birth certificate does not include method of finance. Information from the National Governors' Association indicates that the percentage of Medicaid-financed births in Texas rose from 47% in 1995 to 49% in 1997.^18,19 Moreover, the similarity of results with respect to prenatal care and birth outcomes among Latinas in all 3 localities also suggests that there was probably no major shift in the insurance coverage of births among Latinas in Texas during this period.

There are several possible explanations for why we found no adverse consequences associated with PRWORA on the perinatal outcomes of foreign-born Latinas in California, New York City, and Texas. The first may be related to the limitations of vital data. Not all foreign-born Latinas were "exposed" to the restrictions in PRWORA as implemented by each state. Only women who arrived after August 1996 lost Medicaid coverage of prenatal care in Texas or were vulnerable to a cutoff in California and New York. It may be argued, therefore, that the effect of PRWORA on specific subpopulations was not detectable from vital data. However, confusion was widespread in immigrant communities about welfare reform's implications for legal as well as undocumented immigrants. Given the large number of observations and the size of the undocumented population, any significant response to welfare reform among the undocumented alone would have been detectable. In 1995, for instance, there were 74 006 births to undocumented Latino immigrants paid for by Medi-Cal.¹⁸ This represents 57% of the 130 862 foreign-born Latinas in 1995 whose births were financed by Medi-Cal, other publicly funded programs, or self-pay. Similarly, in Texas there were 27 980 inpatient stays by undocumented immigrants under emergency medical assistance or emergency "spend-down programs," by which people may be eligible for emergency medical assistance under Medicaid if a large medical bill, when deducted from their income, brings them below the income eligibility threshold for Medicaid. Since 90% of all inpatient stays financed by Medicaid were obstetric, there were approximately 25 000 deliveries to undocumented immigrants in 1995.²⁰ These births represent 38% of the 65 219 deliveries to foreign-born Latinas in the state. Thus, in both California and Texas, a large proportion of foreign-born Latinas who gave birth in 1998 may have been—or may have perceived themselves to be—ineligible for Medicaid coverage of prenatal care and delivery because of PRWORA.

Another explanation for the lack of an effect of PRWORA on perinatal outcomes in California and New York City is that eligibility for publicly funded prenatal care among immigrants was essentially unchanged. This is true for New York City under the Lewis decision,¹ where federal matching funds continue to be available for Medicaid coverage of prenatal care for undocumented immigrants. In California, however, there was much greater uncertainty regarding the financing of prenatal care, although coverage was not withdrawn. The openly anti-immigrant atmosphere characterized by Proposition 187 supported the observation by advocates for immigrants that even with the state's replacement of lost federal benefits, many foreign-born women—especially those who were undocumented—remained confused as to their eligibility for Medicaid and fearful of the scrutiny that may have resulted from the legislation. Upon enactment of PRWORA, thenGovernor Wilson of California quickly moved to end the state's prenatal care benefits for the undocumented, and he opposed the state legislature's proposal to use state funds to replace federal funds withdrawn by PRWORA for new legal immigrants (California Department of Health Services, unpublished data, 1996). Moreover, even legal immigrants who arrived before August 1996 felt vulnerable. Shortly after the passage of Proposition 187, for instance, the California Department of Health Services began a joint program with the federal Immigration and Naturalization Service to screen legal nonresidents returning to the country about past use of public benefits, including Medi-Cal, particularly for childbirth.²

In Texas, however, the loss of Medicaid financing of prenatal care for unqualified immigrants under PRWORA was almost immediate. Thus, unlike in California and New York City, confusion as to eligibility for Medicaid benefits in Texas was accompanied by an actual withdrawal of benefits for unqualified immigrants. Our finding of no change in early initiation of prenatal care and low birthweight among foreign-born compared with US-born Latinas in Texas is compelling evidence that PRWORA has had no detectable impact on the perinatal outcomes of foreign-born women.

In addition to the reasons given above, any impact of welfare reform on perinatal outcomes was probably diminished in all 3 localities by the following: (1) the effectiveness of presumptive eligibility and other mechanisms for simplifying access to prenatal care; (2) the powerful incentives that hospitals have to facilitate Medicaid applications in obstetric cases; (3) the availability of prenatal care providers that remain accessible to all immigrants, such as those funded through Title V block grants, or the willingness of prenatal care providers to accept women without regard to ability to pay. In sum, PRWORA appears to have had little immediate effect on the perinatal health and health care utilization of foreign-born Latinas in 3 localities with large immigrant populations.

	Acknowledgments

 
The research was supported by grants from the Health Resources and Services Administration (grant R40MC00126) and the New York Community Trust to the State University of New York Health Science Center at Brooklyn.

Birth certificate data for New York City are from the Office of Vital Statistics, New York City Department of Health.

	Footnotes

 
Note. All opinions expressed are those of the authors and not those of the Health Resources and Services Administration, the New York Community Trust, the State University of New York Health Science Center at Brooklyn, or the New York City Department of Health.

T. Joyce, H. Minkoff, and R. Kaestner planned the study. T. Joyce analyzed the data and took the lead in writing the paper. T. Bauer did the research on the state policies. All authors contributed to the writing of the paper.

Peer Reviewed

Accepted for publication January 5, 2001.

	References

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1. Lewis v Grinker, Civil Action No. CV 79-1740, Memorandum of Law in Opposition to the Federal Defendant's Motion for a Judgment on the Pleadings (EDNY 1999).

2. Park LS, Sarnoff R, Bender C, Korenbrot CC. Impact of recent welfare and immigration reforms on use of Medicaid for prenatal care by immigrants in California. J Immigrant Health.2000;2:5–22.

3. Minkoff H, Bauer T, Joyce T. Welfare reform and the obstetrical care of immigrants and their newborns. N Engl J Med. 1997;337:705–707.[Free Full Text]

4. Ellwood M, Ku L. Welfare and immigration reforms: unintended side effects for Medicaid. Health Aff.1998;17:137–151.[Abstract]

5. Schlosberg C, Wiley D. The impact of INS public charge determinations on immigrant access to health care, National Health Law Program, National Immigration Law Center, May 22, 1998, posted on June 24, 1998. Available at: www.healthlaw.org/pubs/19980522publiccharge.html. Accessed August 31, 2001.

6. Wise P, Chavkin W, Romero D. Assessing the effects of welfare reform policies on reproductive and infant health. Am J Public Health.1999;89:1514–1521.[Abstract/Free Full Text]

7. Zimmerman W, Fix M. Declining Immigrant Applications for Medi-Cal and Welfare Benefits in Los Angeles County. Washington, DC: Urban Institute; 1998.

8. Jessop D, Finkelstein R, Rosenberg T, et al. The Impact of Recent Immigration Policy Changes on the Receipt of WIC Services: An Aggregate Analysis. New York, NY: Medical and Health Research Association; 1999.

9. Perry MJ, Sytark E, Burciaga Valdez R. Barriers to Medi-Cal enrollment and ideas for improving enrollment: findings from eight focus groups in California with parents of potentially eligible children. Report prepared for the Kaiser Family Foundation, October 1998. Available at: http://www.kff.org/content/archive/1436. Accessed October 1999.

10. Andrulis D, Bauer T, Hopkins S. Voices for Children's Health in New York State: Community Roundtables on Increasing Medicaid and Child Health Plus Enrollment. New York Forum for Child Health, New York Academy of Medicine, 1999 Available at: http://www.nyam.org/publications/online/childinsurance/Round.pdf. Accessed March 2000.

11. Braveman P, Bennett T, Lewis C, et al. Access to prenatal care following major Medicaid eligibility expansions. JAMA.1993;269:1285–1289.[Abstract/Free Full Text]

12. Joyce T. Impact of augmented prenatal care on birth outcomes of Medicaid recipients in New York City. J Health Econ.1999;18:31–67.[Medline]

13. Fix M, Passel J. Trends in Noncitizens' and Citizens' Use of Public Benefits Following Welfare Reform: 1994–1997. Washington, DC: Urban Institute; 1999.

14. Lewin J. Protecting the health of children of immigrants. Innocent victims of adult policy. JAMA.1997;277:672.[Abstract/Free Full Text]

15. Brown ER, Wallace SP, Pourat N, Yu H. New estimates find 400 000 children eligible for healthy families program. University of California at Los Angeles Center for Health Policy Research, October 1998. Available at: http://www.healthpolicy.ucla.edu/publications/NewEstimatesPolicyBrief.pdf. Accessed November 1999.

16. California Dept of Health Services. Medi-Cal funded deliveries 1995. January 1997. Available at: http://www.dhs.ca.gov/mcss/PublishedReports/Delivery/95/del95.pdf. Accessed November 1999.

17. California Dept of Health Services. Medi-Cal funded deliveries 1998. May 2000. Available at: http://www.dhs.ca.gov/mcss/PublishedReports/Delivery/98/del98.pdf. Accessed October 2000.

18. National Governors' Association. MCH update: state Medicaid coverage of pregnant women and children. September 30, 1997. Available at: http://www.nga.org/Pubs/IssueBriefs/2000/MCHUpdateTables.pdf and http://www.nga.org/Pubs/IssueBriefs/1997/970930MCHUpdate.asp. Accessed October 2000.

19. National Governors' Association. MCH update: income eligibility for pregnant women and children. January 2000. Available at: http://www.nga.org/Pubs/IssueBriefs/2000/MCHUpdateTables.pdf. Accessed October 2000.

20. Medicaid Annual Hospital Discharge Report: Fiscal Year 1995. Austin: Texas Dept of Health; 1997.

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This Article Abstract Figures Only Full Text (PDF) Submit a response View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Joyce, T. Articles by Kaestner, R. Search for Related Content PubMed PubMed Citation Articles by Joyce, T. Articles by Kaestner, R.