Elizabeth A. Greener
Published: 2020
Total Pages: 0
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Background and Objectives: The number of US women using drugs during pregnancy has increased over the last decades, warranting concern as prenatal substance exposure (PSE) is associated with poor maternal and infant health outcomes. Policymakers have responded with child welfare laws targeting PSE, by designating behavioral and reproductive healthcare services as essential health benefits in the Affordable Care Act (ACA), and by expanding Medicaid eligibility thresholds. The goals of these policies are to curtail drug use during pregnancy, increase healthcare coverage, expand access to services, and improve outcomes. Minimal work has studied the impact of these policy changes on pregnant women seeking specialty substance use disorder (SUD) treatment, infant mortality, and maternal mortality. This dissertation seeks to understand the impact of ACA Medicaid expansion on (1) pregnant women seeking specialty substance use disorder treatment; and further evaluate how Medicaid expansion and prenatal substance exposure child abuse laws impact (2) infant, and (3) maternal mortality. Data and Design: Data were obtained for 2011-2017 from the Treatment Episode Data Set-Admissions (TEDS-A), for 2003-2017 from the National Center for Health Statistics (NCHS) natality and all-cause mortality files. We used difference-in-differences multivariable models to compare (1) differences in expansion and non-expansion states on wait time to treatment entry and rates of planned medication treatment for opioid use disorder (MOUD), (2) infant mortality and (3) maternal mortality in states with and without PSE child abuse laws in the context of ACA Medicaid expansion. Results: Medicaid expansion was associated with shorter wait times for treatment entry and increased planned use of MOUD. PSE child abuse laws were not associated with statistically significant changes in infant mortality when accounting for Medicaid expansion. States without PSE child abuse laws that adopted Medicaid expansion had a relative decrease in maternal mortality, however this change was not statistically significant. Conclusion: ACA Medicaid expansion is associated with improved access to care and better treatment for pregnant populations. PSE laws do appear to influence infant and maternal mortality, yet it is unclear whether that influence is meaningful in the context of ACA Medicaid expansion. Policy Implications: Medicaid expansion is associated with increased access to healthcare services, and PSE child abuse laws directly influence the strength of that effect. States governments are in a unique position to implement policies that can improve healthcare coverage and encourage at risk populations to interact with the healthcare system.
