Inadequate prenatal care in Texas: What we can learn about improving access in the coming expansion of Medicaid

While the Patient Protection and Affordable Care Act expands healthcare coverage to the previously uninsured, policy experts question the capacity to provide care for newly Medicaid-eligible populations. Despite Medicaid's relative success covering tens of millions of low-income people, access problems remain ahead of the 2014 expansion, projected to add some 15-16 million to state Medicaid roles. We conducted an analysis of 3,292 women between 2000-2004, with Medicaid as the primary payer of the birth and for those receiving less than adequate prenatal care as defined by the Kessner Index. The study area consisted of a five county region (Liberty, Hardin, Orange, Jefferson and Chambers) in Texas, home to the Beaumont-Port Arthur Metropolitan Statistical Area. Although women with Medicaid-covered births are of low socioeconomic strata, they are a diverse group of individuals. Developing a typology of the subgroups among those receiving less than adequate prenatal care into a coherent scheme may be useful in targeting those with access barriers. Using two-stage cluster analysis and Geographic Information Systems, we identified subgroups of women using personal information derived from vital records data, such as ethnicity, age and educational level of the mother. In addition, we added a number of contextual variables to each birth record from the US Census, such as poverty rates, automobile ownership and English proficiency by Zip Code Tabulation Area (ZCTA). We also added a number of healthcare availability variables to each birth record using data from the Health Resources and Services Administration, such as the presence of a Medically Underserved Area and the availability of an active OB/GYN by ZCTA. By examining individual, spatial and contextual factors of women with less than adequate prenatal care access, our analysis resulted in an optimal solution of four clusters. The most dominant factors associated with the clusters were distance to the nearest community health center, percent of households receiving public assistance, and percent of households without an automobile. The results should continue to remind policymakers that the provision of insurance coverage alone does not necessarily equate to access of healthcare services, especially among low-income populations. Improved access must be the result of insurance coverage coupled with a deeper understanding of the barriers and needs specific subgroups are likely to face. Only by fully understanding access barriers to care can appropriate interventions be developed to ensure that recent investments in Medicaid expansion will result in appropriate access to the healthcare system.