Pregnant people with substance use disorders (SUD) are at high risk of potentially avoidable morbidity and mortality. In particular, pregnant people with opioid use disorder (OUD) have experienced large increases in maternal mortality, largely driven by rising rates of drug overdose. The majority of pregnant people with SUD receive health insurance through state Medicaid programs, many of which use private Medicaid managed care (MMC) plans to finance and deliver health care services rather than through the state-run fee-for-service (FFS) plan. MMC plans receive capitated payments in exchange for coverage of a defined set of benefits. Pregnant people with SUD are predictably high-cost and high-need, and MMC plans may not be able to recoup the high cost of services used over often short periods of enrollment associated with pregnancy.
While capitation may incentivize MMC plans to promote access to high-value services that reduce the risk of poor maternal health outcomes, it might also incentivize plans to restrict access to certain services or alter their provider networks in ways that reduce costs. Despite being the dominant delivery vehicle of insurance coverage to this growing population, no research has examined the association between MMC enrollment and maternal health outcomes among pregnant people with any SUD or with OUD.
In this Dissertation, I use the newly-available Transformed Medicaid Statistical Information System Analytic Files (TAF) across all three studies. The newly-available TAF files contain claims data for all Medicaid enrollees from all 50 states and the District of Columbia, and represent the most comprehensive data source for longitudinal inpatient and outpatient health service utilization among Medicaid enrollees. In the first study, I develop and validate an algorithm to identify live births using the TAF data. I find that using claims in both the inpatient and other services files are critical to accurately capture live births at the state-year and state-month level.
In the second study, I first estimate the burden of SUD and OUD among pregnant people enrolled in Medicaid, and the prevalence of adverse maternal health outcomes in these groups. Next, I examine the association of severe maternal morbidity (SMM) and MMC enrollment among pregnant people with SUD and, separately, OUD nationally from 2016-2018. I find that SMM within six weeks of delivery is more prevalent among those with any SUD (3.2%) and OUD (3.9%) than those without either diagnosis (1.6%). Moreover, I find that enrollment in MMC (vs. Medicaid FFS) is associated with a 0.54 percentage-point (pp) and a 0.66 pp reduction in the probability of SMM among those with any SUD and among those with OUD, respectively.
In the third study, I estimate the effect of MMC enrollment on adverse maternal health outcomes using data from two states (Illinois and Missouri) that expanded MMC to statewide. Using difference-in-differences models, I find that expansion of MMC did not change the probability of adverse maternal health outcomes among pregnant people with any SUD. These results suggest that at a minimum MMC has not worsened health outcomes among those with SUD, and at best, MMC may be driving incremental improvements for this group at high-risk of morbidity and mortality. / 2025-07-25T00:00:00Z
| Identifer | oai:union.ndltd.org:bu.edu/oai:open.bu.edu:2144/46498 |
| Date | 26 July 2023 |
| Creators | Auty, Samantha G. |
| Contributors | Frakt, Austin B. |
| Source Sets | Boston University |
| Language | en_US |
| Detected Language | English |
| Type | Thesis/Dissertation |
| Rights | Attribution-NonCommercial-NoDerivatives 4.0 International, http://creativecommons.org/licenses/by-nc-nd/4.0/ |
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