A generation after the U.S. expanded safety-net health coverage to pregnant women who would otherwise be uninsured, their grandchildren are still reaping the benefits, a new study suggests.
A new economic paper that examines the long-term benefits of Medicaid coverage for pregnant women suggests that when babies born with coverage grew up and started families of their own, those kids had higher average birth weights. The number of children born with extremely low birth weights, a serious condition, also fell.
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Scientists know that conditions during gestation and birth can have long-lasting consequences. Generations born during famines, for example, had poorer health throughout their lives. One study found that children exposed in utero to radiation from nuclear testing in Norway in the 1950s and '60s grew up to have lower IQs, less education and lower earnings. Some effects seemed to be passed on to their children, too.
Recent research suggests that people who have health insurance from infancy experience benefits later in life. "When they grew up, they actually had fewer hospitalizations, were less likely to have diabetes [and] other chronic illnesses," said Sarah Miller, an economist at the University of Michigan who co-authored the recent paper on prenatal Medicaid coverage. The study, released as a working paper, has not yet been published in a peer-reviewed journal.
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Today, Medicaid pays for about half of all births in the United States, largely because in the 1980s, many states, concerned about how many American babies were dying, expanded coverage to pregnant women and children. In the study, economists used those differences in timing and eligibility requirements to examine how the changes might have affected people born under different criteria—and their children.Since every birth certificate lists the mother's date and place of birth, Miller and her colleagues were able to match the health of children born recently—from 1994 to 2015—with information on whether each child's mother was likely to have been eligible for Medicaid when she was born. Then they examined how the mothers' Medicaid eligibility at birth was linked to the next generation's birth weight and prematurity.
The researchers had no way to tell whether any given mother had been covered by Medicaid at birth. Instead, they looked at changes in how many people would have been eligible for Medicaid and how that was associated with birth outcomes for their children.
While expanded Medicaid coverage didn't seem to reduce the number of premature births in the next generation, it did improve average birth weight and reduce the number of kids born at very low birth weights.
The finding is consistent with an idea called the fetal origins hypothesis, which posits that a mother's health and environment during pregnancy can have long-lasting effects on her baby that aren't detected until later in life. "The effects of in utero exposure can persist into the second generation," said Sandra Black, an economist at the University of Texas-Austin who documented such changes from radiation exposure and who was not involved with the new paper. "While it is not surprising, it is particularly hard to identify, which is why this paper will be important," she wrote in an email.
It's unclear whether the benefits the '80s Medicaid expansion conferred on a younger generation were strictly the product of improvements in mothers' health, or if such other factors as income played a role, too. "The truth is that your health can also affect economic success and your ability to complete school," Miller said. Likewise, income can influence physical health. "It's not really an either/or sort of situation."
A growing body of evidence suggests that policies to improve maternal and child health may have broad societal benefits. That could mean "existing benefit-cost calculations underestimate the true value of government investment in children's health," the study's authors write.
Medicaid was created in 1965 to provide safety-net health-care coverage for poor families on welfare. Today, it insures 72 million people, including 28 million children, and has expanded coverage beyond those eligible for welfare to many other people with low incomes. The federal government and states collectively spent $545 billion on the program in 2015, but it has recently been targeted for funding cuts in various Republican-backed bills intended to dismantle the Affordable Care Act.
Critics sometimes question whether Medicaid improves people's health. A famous 2013 study in Oregon found that people who were randomly selected to get health coverage didn't experience measurable improvements in physical health over two years, although having Medicaid did reduce their rates of depression and their financial burdens.
But, at least for children whom the program reaches in utero, the benefits of Medicaid coverage may be long-lasting—and difficult to measure. Many of the mothers who got expanded prenatal care might have been fine without it, but for a small number it made a big difference, Miller said. "It seems like it is having a very strong impact on a relatively small group of women that are really at risk," she said. "For the group of women that really needed the care, the effect is potentially very large."
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