Journal of Policy Analysis and Management最新文献

Current U.S. law mandates notification of substance-affected infants to state child welfare systems (CWS) for the purpose of assessment and service connections. Yet, CWS appears to identify a small share of substance-affected infants at birth, potentially reflecting inconsistent diagnosis of prenatal substance exposure (PSE) and emerging efforts to limit toxicology testing. This study uses linked maternal and child administrative records (2015 to 2021) for Pennsylvania Medicaid-covered births with CWS cases by age 3 (N = 31,913) to investigate PSE prevalence. Using indicators from CWS records and both child and maternal Medicaid claims, we estimate that 45% of children involved with CWS by age 3 experienced PSE, as well as 59% of children entering foster care. Nearly half of these children were not involved with CWS at birth and a majority did not receive a medical diagnosis of PSE. Yet, extrapolated estimates suggest that 70% of Medicaid-covered children with a PSE indicator will experience a CWS case by age 3. Absent high uptake of robust supportive interventions from other systems or agencies, avoiding notification of PSE at birth may not reduce long-term involvement with CWS among children with PSE.

The literature remains mixed on the extent to which medical malpractice reforms affect physician overuse of procedures (i.e., “defensive medicine”). We bring new evidence to this discourse by examining a recent reform in North Carolina that introduced caps on noneconomic damages. We focus on a setting where malpractice risk is high and service intensity is strongly subject to physicians’ discretion: obstetrics care. Comparing discharge data from North Carolina to Florida, we show that caps on noneconomic damages causally reduce the likelihood of a cesarean delivery by, on average, 5%, with the effect size nearing 7% five years post-policy implementation. Physicians also substitute away from other intensive procedures such as vacuum and forceps deliveries but maintain control over the timing of births by increasing medical inductions. Our findings suggest that the reduction in cesarean deliveries due to North Carolina's damage caps can reduce annual spending by approximately $4.6 million.

This study considers whether the Affordable Care Act (ACA) Medicaid expansions resulted in changes in the use of non-physician providers. Medicaid expansions may have impacted both payments to providers as well as insurance availability for patients. Using U.S. birth certificate records, we analyze whether the ACA Medicaid expansions influenced the trade-off between physicians and certified nurse-midwives (CNMs/CMs) for obstetric care. Our findings indicate that the ACA Medicaid expansions led to an increase in the utilization of CNMs/CMs and a decrease in physician-reported deliveries. This shift from physicians to CNMs/CMs is particularly noticeable in states with Medicaid reimbursement parity for CNMs/CMs. These results suggest that health insurance expansions may increase the use of non-physician providers, but only in cases where non-physician providers are reimbursed similarly to physicians.

This paper uses the random assignment of poor families to treatment and control conditions in the Comprehensive Child Development Program (CCDP) to estimate the effects of center-based child care enrollment on child well-being. Implemented in the early-1990s, the CCDP aimed to improve child development and family functioning by offering those in the treatment group 5 years of high-quality child care along with case management. As a result, treated children were substantially more likely to be enrolled in center-based programs throughout the preschool-age years, and I use this variation to estimate the impact of center care on children's language and social skills as well as health. I uncover mixed results: More time spent in center-based settings improves language skills but reduces social skills in the short run, and both effects fade out for most children within 1 to 2 years. I also find that early center care use is strongly predictive of later Head Start enrollment, indicating that a more deliberate “family retention strategy” may be effective at extending children's exposure to high-quality early education.