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Birth outcomes, Medicaid vetted in expansion study

Study: Expansion aids blacks by Kat Stromquist | April 24, 2019 at 4:30 a.m.

Medicaid expansion programs are associated with better outcomes for black babies, a group of researchers primarily from Arkansas has found.

In a study published Tuesday in the Journal of the American Medical Association, the group mostly based at University of Arkansas for Medical Sciences and its Fay W. Boozman College of Public Health found reduced disparities in preterm birth and low birth weight for black infants among states that expanded Medicaid under the Patient Protection and Affordable Care Act.

The 2010 law included provisions allowing states to expand Medicaid programs to cover adults making up to 138 percent of the poverty level.

Although researchers didn't find an overall difference in birth outcomes between states that expanded the program and those that didn't, they uncovered statistically significant improvements for black infants in all four adverse measures they looked at, including low birth weight, very low birth weight, preterm birth and very preterm birth.

"Black infants die of complications associated with prematurity and low birth weight at 3.9 times the rate of white infants," wrote the authors, led by 28-year-old instructor Clare Brown as part of her doctoral dissertation at the public health college. "The findings here suggest that earlier and continual access to insurance coverage may provide an important opportunity for improving infant outcomes."

Researchers employed statistical software to examine more than 15 million births across 35 states and the District of Columbia, using vital records and other data sources.

Because of the manner in which Arkansas expanded Medicaid -- using the "private option," which covered some beneficiaries with commercial insurance plans -- and the timing of its adoption of a new birth certificate format, data from the state were excluded from the analysis.

Still, Brown said in a telephone interview, the findings have local implications.

"I think Arkansas has a relatively high concentration of those who are most at risk for adverse birth outcomes, specifically non-Hispanic black individuals," she said. "What we're arguing is that having insurance prior to pregnancy will allow you to be healthier."

Disparities in black infant mortality have lately been a subject of discussion and alarm in American public health.

As well as higher mortality linked to low birth weight, mortality rates overall and rates of sudden infant death syndrome for black babies more than double those of whites, according to the U.S. Department of Health and Human Services' Office of Minority Health.

Researchers said these results provide a mechanism that potentially explains drops in black infant mortality in Medicaid expansion states established by other studies.

J. Mick Tilford, a co-author and Fay W. Boozman College of Public Health health policy and management professor, says this is the college's first publication in the Journal of the American Medical Association, which is one of the most selective peer-reviewed biomedical journals.

When he saw Brown's findings as a member of her dissertation committee, he urged her to hustle and submit them for publication, for fear they'd "get scooped" by other academics.

"[Brown] did just an amazing analysis of all that data," he said. "While [the result] certainly doesn't justify Medicaid expansion in and of itself, it's certainly something that needs to be considered by politicians and policymakers."

One future avenue for research, Tilford said, is further investigation of large datasets to clarify why there is such a disparity in outcomes between black and white infants, which isn't yet well-understood.

Brown said she'd like to compare data from Arkansas specifically to the findings -- it's possible that the state's private option could lead to different effects within groups, she said.

Researchers said reducing rates of preterm birth and low birth weights is important not just for their own sake, but because of long-term effects on health metrics. Early birth and low birth weight are linked to higher risks of developing chronic conditions, such as heart disease or high blood pressure, later in life.

Under the Medicaid expansion programs, researchers wrote, low-income women also are less subject to insurance "churn," in which they are covered by Medicaid during pregnancy (required by a 1990 federal law) but lose their insurance after giving birth.

The upshot of the findings, Journal of the American Medical Association editors wrote in a note accompanying the study, is that "Medicaid expansion may be helping to reduce racial disparities in one of the most important health indicators of a society -- birth outcomes related to infant mortality."

Additional co-authors on the study included Holly Felix, Kathryn Stewart and T. Mac Bird, who are faculty or former faculty at the public health school; Dr. Curtis Lowery, director of the UAMS Institute for Digital Health & Innovation; and Jennifer Moore, an assistant professor at the University of Michigan Medical School and the executive director of the Institute for Medicaid Innovation Research.

One caveat to the findings is that it may take some time for the full effect of Medicaid expansions to be visible in data, though exactly how long isn't clear.

"Say you got insurance today, you're not going to be healthier today. It may take some time," Brown said.

"[But] if we produce healthier mothers, then we'll produce healthier babies," Tilford added.

Metro on 04/24/2019

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