Graduate Thesis Or Dissertation
 

Effect of Medicaid Expansion on Health Service Utilization during the Postpartum Period among Low-income Women in Oregon

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https://ir.library.oregonstate.edu/concern/graduate_thesis_or_dissertations/f1881v61h

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  • Background: Access to and effective utilization of healthcare services during the postpartum period is essential in preventing and managing health risks among women after childbirth, ensuring a smooth transition to motherhood, and promoting long-term health outcomes for women and their families. Low-income Medicaid women and those belonging to minority race/ethnicity or residing in rural areas bear a disproportionate burden of maternal mortalities and morbidities. Prioritizing reproductive and sexual health, and mental and behavioral health is critical to address the increasing rate of maternal morbidities and mortality in the US, particularly among vulnerable populations. This study examined the effect of Medicaid expansion on sexual and reproductive, and mental and behavioral healthcare services utilization during the postpartum period among low-income women in Oregon who were enrolled in Medicaid. Methods: Informed by the classic Aday and Anderson's (1974) framework for access to health care and using a retrospective pre-post quasi experimental design, I analyzed a linked data set that included Oregon Medicaid eligibility and claims, birth certificate, and hospital discharge data for women aged 18-44 with live births from 2011 through 2015. The outcome binary variables for healthcare utilization within 12 months after delivery included utilization of contraceptive counselling, effective contraceptive methods, STI testing services, mental health treatment services, tobacco cessation treatment services, and alcohol and other substance use treatment services. I hypothesized that Medicaid expansion was associated with increased utilization of healthcare services for women enrolled in Medicaid and across all racial/ethnic categories and rurality groups. I created one pre-Medicaid expansion (2011–2012) and two post-Medicaid expansion (2014–2015) cohorts (i.e., previously covered and newly covered). The post-Medicaid expansion cohorts were my independent variables. I utilized the linear probability regression model and implemented the single interrupted time series design. The post-Medicaid expansion cohorts served as the main independent variables. Results: Medicaid expansion in Oregon had mixed effects on the utilization of services by low-income women during the postpartum period, varying by type of services and post-Medicaid expansion cohort. Overall, both previously and newly enrolled women had similar gains, although in different types of services. Among the previously enrolled cohort, I found higher likelihood of utilization in the effective contraceptive methods (2.03 percentage points; 𝑝 <0.01), mental health services (7.88 percentage points; 𝑝 <0.001) and alcohol and substance use treatment services (4.81 percentage points; 𝑝 <0.001). Among the newly enrolled cohort, Medicaid expansion was associated with higher likelihood of utilization in contraceptive methods (2.68 percentage points; 𝑝 <0.01), mental health care utilization among all women (8.60 percentage points; 𝑝 <0.001) and among those with SMI (5.3 percentage points; 𝑝 <0.05). However, the utilization of contraceptive counselling services, STI screening methods, and tobacco cessation services did not change following Medicaid expansion in either post-Medicaid expansion cohort. I found that impact of Medicaid expansion was moderated by race/ethnicity, varying by types of services. Hispanic women experienced the largest gains in the utilization of contraceptive methods (previously enrolled cohort – 8.43 percentage points, 𝑝 <0.001; newly enrolled cohort – 5.81 percentage points; 𝑝 <0.01), and mental health care services (previously enrolled cohort – 13.65 percentage points, 𝑝 <0.001; newly enrolled cohort – 14.82 percentage points; 𝑝 <0.001), and STI services (newly enrolled cohort – 0.30 percentage points; 𝑝 <0.01). Asian women also experienced increased utilization of effective contraceptive methods (previously enrolled cohort – 10.69 percentage points, 𝑝 <0.001), mental healthcare (previously enrolled cohort – 11.56 percentage points; 𝑝 <0.001) and mental health care utilization among SMI subsample (newly enrolled cohort – 14.35 percentage points; 𝑝 <0.05). AIAN women experienced increased utilization only for alcohol and substance use treatment services (previously enrolled cohort – 14.60 percentage points; 𝑝 <0.001). White women also experienced increased utilization of services, specifically in mental health care services (previously enrolled cohort – 4.09 percentage points; 𝑝 <0.01), and alcohol and substance abuse services (previously enrolled cohort – 13.65 percentage points, 𝑝 <0.001; newly enrolled cohort – 14.82 percentage points; 𝑝 <0.001). The impact of Medicaid expansion was also moderated by rurality, varying by types of services. Urban women, and those in the previously enrolled cohorts made maximum gains in utilization of services following Medicaid expansion. Urban women had higher likelihood of utilization of contraceptive methods (previously enrolled - 1.94 percentage points; 𝑝 <0.01), mental health care services among all women (previously enrolled cohort – 7.44 percentage points, 𝑝 <0.001; newly enrolled cohort – 8.52 percentage points; 𝑝 <0.01) and among those with SMI (newly enrolled cohort – 4.57 percentage points; 𝑝 <0.01), and alcohol and substance use services (previously enrolled cohort – 4.06 percentage points; 𝑝 <0.05). Women from large rural areas experienced increased utilization only for mental health services (previously enrolled cohort – 10.92 percentage points, 𝑝 <0.001; newly enrolled cohort – 10.25 percentage points; 𝑝 <0.001). Lastly, women residing in the small rural areas experienced gains in contraceptive method utilization (previously enrolled cohort – 7.08 percentage points; 𝑝 <0.001), mental health care service utilization (previously enrolled cohort – 7.73 percentage points; 𝑝 <0.001), and utilization of alcohol and other substance use services (previously enrolled cohort – 21.21 percentage points; 𝑝 <0.001). Implications/Conclusion: The research findings indicated that when considering policy and practice implications, it is crucial to acknowledge that factors beyond increased insurance coverage influence healthcare utilization. A comprehensive healthcare system must recognize and address socio-cultural determinants of health and leverage policy measures to mitigate these disparities. This research highlighted the positive outcomes of Oregon's Medicaid expansion in enhancing healthcare utilization during the postpartum period. However, the findings also underscored the limitation of a policy primarily focused on expanding health insurance coverage to increase utilization. Including the multiple influences on healthcare utilization, such as socioeconomic factors and cultural determinants of health, are essential when designing polices, practices, and strategies to enhance healthcare utilization among new mothers and potentially reduce maternal morbidities and mortality.
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