Abstract
I examined the impact of state expansions in eligibility for Medicaid family planning services on the utilization of Papanicolaou (Pap) tests, clinical breast examinations, HIV testing, and routine doctor check-ups among women aged 21 to 44 years using the Behavioral Risk Factor Surveillance System (1993–2009). Using a natural experiment approach, I found significant increases in Pap tests and clinical breast examinations among women eligible for services under the expansions but no significant change in HIV testing or routine doctor check-ups.
Since 1964, the US government has subsidized contraceptive and related preventive services for low-income women under national family planning policy. The primary goal of this policy is to reduce the number of unplanned pregnancies by increasing access to contraceptive services, supplies, and education.1 However, public family planning providers also offer important preventive services for women, including screenings for breast and cervical cancers and sexually transmitted infections. For women without health insurance or access to affordable health care, the impact of this subsidy on the utilization of these services could be large.
I examined the impact of expanded access to Medicaid family planning services on the utilization of related preventive care among low-income women aged 21 to 44 years. Between 1994 and 2011, 22 states established demonstration programs that expanded income eligibility for Medicaid family planning services to women who would otherwise be ineligible for Medicaid.2 To my knowledge, this study is among the first to examine the impact of these expansions on the use of preventive health care.3
METHODS
In the analysis, I used data from the Behavioral Risk Factor Surveillance System from before and after the expansions (1993–2009) in states with and without expanded programs to examine changes in utilization among women eligible for services compared with those with higher incomes. The Behavioral Risk Factor Surveillance System is a nationally representative survey conducted annually by state health departments via landline telephone to collect information on adult health behaviors and practices.4 Dependent variables indicate whether the respondent had a Papanicolaou (Pap) test, a clinical breast examination, or a routine doctor check-up in the past 12 months and whether the respondent has ever been tested for HIV. An additional dependent variable indicated whether a woman received a Pap test within the past 3 years as recommended during this period.5–7
The sample for each dependent variable included survey years for which the corresponding survey question was asked of all participating states (1993–2000, 2002, 2004, 2006, 2008 for Pap tests and clinical breast exams; 1993–2000 and 2005–2009 for routine doctor visits; 1993–2009 for HIV tests). I examined women of reproductive age beginning at 21 years to align with current screening guidelines. When examining Pap tests, I restricted the sample to women with an intact cervix. In the analysis for Pap test receipt within a 3-year interval, I also excluded women residing in states with programs implemented in 2003 or later to allow enough time for evaluation.
I estimated a multivariate linear probability model in which the independent variable of interest is the interaction of an indicator of the presence of a Medicaid family planning program in a given state and year and an indicator of individual eligibility status. I estimated whether individuals were eligible for the expansions using information on household income and the income eligibility threshold for the expansion in each state. For states without expansions, I used a hypothetical income threshold to identify a group of women who were comparable to eligible women in the expansion states. Other independent variables I included in the regression were state, year, and state–year interaction dummies; an indicator of individual eligibility status for the expansions and its interactions with state and year dummies; and individual-level characteristics (age dummies, indicators for Black and other race categories, Hispanic origin, married, employed, highest level of educational attainment [high school graduate, some college, or college graduate], and number of children in the household).
I employed survey weights in all analyses and performed analyses using Stata/SE version 12.1 (StataCorp LP, College Station, TX). SEs were heteroskedasticity-robust and clustered at the state (intervention) level to account for serial correlation.8 I conducted several sensitivity analyses testing different specifications. Additional information on methods and robustness checks is available in Wherry.2
RESULTS
Table 1 presents the estimation results from the analysis. The parameter estimates on the interaction term provide estimates for the effect of the family planning expansions on eligible women. The results indicate that the expansions increased the probability of receiving a Pap test within the past 12 months by 2.8 percentage points for eligible women in expansion states. The probability of receiving a clinical breast examination within the past 12 months increased by 1.6 percentage points. Combined with an estimate of the change in participation in Medicaid family planning services under the expansions,9 these estimates imply a 19.0% increase in Pap test receipt and a 10.9% increase in clinical breast examination receipt within a 12-month period among new program enrollees. In addition, there was a 2.2 percentage point increase in the probability of meeting the recommendation for receiving a Pap test within the past 3 years, an implied increase of 14.9% among new enrollees. There is no significant evidence of a change in routine check-ups or of ever being tested for HIV among eligible women under the expansions.
TABLE 1—
Impact of Medicaid Family Planning Expansions on Preventive Services Use Among Eligible Women Aged 21–44 Years: Behavioral Risk Factor Surveillance System, United States, 1993–2009
| Pap Test Within Past 12 Months | Pap Test Within Past 3 Years | CBE Within Past 12 Months | Ever Tested for HIV | Routine Check-Up Within Past 12 Months | |
| Expansion state × eligible, change in probability (SE) | 0.028** (0.010) | 0.022* (0.010) | 0.016* (0.008) | −0.006 (0.008) | −0.010 (0.010) |
| Eligible, change in probability (SE) | −0.106** (0.011) | −0.062** (0.007) | −0.129** (0.011) | 0.063** (0.016) | −0.098** (0.008) |
| Baseline probability for eligible women in expansion states | 0.659 | 0.840 | 0.583 | 0.566 | 0.682 |
| Implied change for new Medicaid family planning enrollees, % | 19.0 | 14.9 | 10.9 | … | … |
| Observations, no. | 438 824 | 311 642 | 484 558 | 750 354 | 556 762 |
Note. CBE = clinical breast examination. SEs are clustered by state. I calculated weighted baseline means using preexpansion observations in states adopting expansions. I calculated the implied change in screening behavior among new Medicaid family planning enrollees using an estimate of the change in participation in Medicaid family planning services under the expansions from Kearney and Levine9 and the share of women in the Behavioral Risk Factor Surveillance System sample eligible for the expansions (see Wherry2 for additional information).
*P < .05; **P < .01.
The estimated parameters on the eligibility indicator provide regression-adjusted estimates of the gaps in utilization between eligible and higher income women. Comparing these estimates with the estimated impact of the expansions revealed that the family planning programs reduced the size of the gaps in utilization of Pap tests and clinical breast examinations over a 12-month period by one quarter and one tenth, respectively. The expansions reduced the gap in screening for cervical cancer over a 3-year period by more than one third.
DISCUSSION
The evidence I have presented shows that previous state expansions in Medicaid family planning services increased screenings for breast and cervical cancer among low-income women and narrowed the gap in the utilization of these services when compared with higher income women. Under the 2010 Patient Protection and Affordable Care Act, it is now easier for states to expand eligibility for Medicaid family planning services.10 These results show that expanded Medicaid family planning programs play an important role in providing access to certain preventive services in addition to contraception.
Acknowledgments
The Robert Wood Johnson Foundation Health & Society Scholars program and the Agency for Healthcare Research and Quality T-32 Predoctoral Training Grant in Health Services Research at the University of Chicago supported this work.
I would like to thank Dan Black, Kerwin Charles, and David Meltzer for feedback on earlier drafts, as well as Sarah Cattan, Melissa Gilliam, Genevieve Kenney, Robert LaLonde, Lindsey Leininger, Willard Manning, Bruce Meyer, Nikolas Mittag, Brendan Saloner, Daniel Schmierer, and Matthew Stagner for additional comments, and numerous seminar participants for helpful advice. In addition, I thank Erin McCarthy at the Guttmacher Institute for providing archived reports on state Medicaid family planning waivers.
Human Participant Protection
Institutional review board evaluation was not necessary because data were obtained from secondary sources.
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