Medicaid costs and birth outcomes: the effects of prenatal WIC participation and the use of prenatal care.

This study examines the effects of prenatal WIC participation and the use of prenatal care on Medicaid costs and birth outcomes in five states--Florida, Minnesota, North Carolina, South Carolina, and Texas. The study period is 1987 for Florida, Minnesota, North Carolina, and South Carolina and January-June 1988 for Texas. Prenatal WIC participation was associated with substantial savings in Medicaid costs during the first 60 days after birth, with estimates ranging from $277 in Minnesota to $598 in North Carolina. For every dollar spent on the prenatal WIC program, the associated savings in Medicaid costs during the first 60 days ranged from $1.77 to $3.13 across the five states. Receiving inadequate levels of prenatal care was associated with increases in Medicaid costs ranging from $210 in Florida to $1,184 in Minnesota. Prenatal WIC participation was associated with higher newborn birthweight, while receiving inadequate prenatal care was associated with lower birthweight.     

Does WIC work? The effects of WIC on pregnancy and birth outcomes

Support for WIC, the Special Supplemental Nutrition Program for Women, Infants, and Children, is based on the belief that "WIC works." This consensus has lately been questioned by researchers who point out that most WIC research fails to properly control for selection into the program. This paper evaluates the selection problem using rich data from the national Pregnancy Risk Assessment Monitoring System. We show that relative to Medicaid mothers, all of whom are eligible for WIC, WIC participants are negatively selected on a wide array of observable dimensions, and yet WIC participation is associated with improved birth outcomes, even after controlling for observables and for a full set of state-year interactions intended to capture unobservables that vary at the state-year level. The positive impacts of WIC are larger among subsets of even more disadvantaged women, such as those who received public assistance last year, single high school dropouts, and teen mothers.     

Reassessing the WIC effect: evidence from the Pregnancy Nutrition Surveillance System.

Recent analyses differ on how effective the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) is at improving infant health. We use data from nine states that participate in the Pregnancy Nutrition Surveillance System to address limitations in previous work. With information on the mother's timing of WIC enrollment, we test whether greater exposure to WIC is associated with less smoking, improved weight gain during pregnancy, better birth outcomes, and greater likelihood of breastfeeding. Our results suggest that much of the often reported association between WIC and lower rates of preterm birth is likely spurious, the result of gestational age bias. We find modest effects of WIC on fetal growth, inconsistent associations between WIC and smoking, limited associations with gestational weight gain, and some relationship with breastfeeding. A WIC effect exists, but on fewer margins and with less impact than has been claimed by policy analysts and advocates.     

Effects of the Minimum Wage on Infant Health

The minimum wage has increased in multiple states over the past three decades and it continues to be a controversial policy. Most prior research has examined the effect of the minimum wage on employment and wages. In this study, we examine the impact of the state minimum wage on infant health. Using data on the universe of births in the U.S. over 24 years, we find that an increase in the minimum wage is associated with a small, but statistically significant increase in birthweight driven primarily by increased fetal growth rate. Effects are largest for young, married mothers. In terms of mechanisms, we find no evidence that prenatal care use and smoking during pregnancy are channels through which minimum wage improves infant health.     

Information Shocks and the Take‐Up of Social Programs

The causes of participation in social programs have been studied extensively, with prominent roles found for program rules and benefits. A lack of information about these programs has been suggested as a cause of low participation rates among certain groups, but it is often difficult to distinguish between the role of information sharing and other features of a neighborhood, such as factors that are common to people of the same ethnicities or socioeconomic opportunities, or uniquely local methods of program implementation. We seek to gain new insight into the potential role of information flows by investigating what happens when information is disrupted. We exploit rich microdata from Florida vital records and program participation files to explore declines in Women, Infants, and Children (WIC) participation during pregnancy among foreign‐born Hispanics in the “information shock” period surrounding welfare reform. We identify how the size of these reductions is affected by having a high density of neighbors from the same place of origin. Specifically, we compare changes in WIC participation among Hispanic immigrants living in neighborhoods with a larger concentration of own‐origin immigrants to those with a smaller concentration of own‐origin immigrants, holding constant the size of the immigrant population and the share of immigrants in the neighborhood who are Hispanic. We find strong evidence that having a denser network of own‐origin immigrants mediated the information shock faced by immigrant women in the wake of welfare reform.     

Public Housing Residence and College Performance: Evidence From the Nation's Largest Urban Public University

Despite clear implications for human capital accumulation, there has been little research on the postsecondary educational experiences of students living in public housing. While there is significant and growing research exploring outcomes for public housing tenants, even in the education sphere, little of this work focuses on postsecondary outcomes and what role, if any, public housing plays in human capital accumulation. Our case study, New York City, is home to both the nation's largest urban public university system and the largest public housing authority. In this work, we use matching techniques to identify and describe the residential characteristics of students at the City University of New York. We explore how students who live in public housing developments differ from their peers in terms of characteristics associated with success in college, including demographics, neighborhood poverty, and high school preparation. We use regression techniques to test the relation between public housing residence, neighborhood income, and two indicators of early college performance: successful completion of credits attempted and one-year retention. In a naive model (including only residence and high school characteristics), public housing residence is negatively associated with our outcomes of interest, but less so when we control for other factors, including neighborhood income. Specifically, for students pursuing an associate's degree, we find a negative relation between public housing residence and credit completion and a less pronounced negative relation with retention. We find no significant relation between public housing residence and either baccalaureate outcome.     

Worth the Wait? The Effect of Early Term Birth on Maternal and Infant Health

Early term birth is defined as birth at 37 or 38 weeks gestation. While infants born early term are not considered premature, the medical literature suggests that they have an increased risk of serious adverse health outcomes compared to infants born at term (39 or 40 weeks). Despite these known harms, we document a rise in early term births in the United States from 1989 to the mid‐2000s, followed by a decline in recent years. We posit that the recent decline in early term births has been driven by changes in medical practice advocated by the American College of Obstetricians and Gynecologists, programs such as the March of Dimes’ “Worth the Wait” campaign, and by Medicaid policy. We first show that this pattern cannot be attributed to changes in the demographic composition of mothers, and provide some evidence that efforts to reduce early term elective deliveries (EEDs) through Medicaid policy were effective. We next exploit county‐level variation in the timing of these changes in medical practice to examine the effect of early term inductions (our proxy for EEDs) on infant and maternal health. We find that early term inductions lower birth weights and increase the risks of precipitous labor, birth injury, and required ventilation. Our results suggest that reductions in early term inductions can explain about one‐third of the overall increase in birth weights between 2010 and 2013 for births at 37 weeks gestation and above.     

When is Growth Not Growth? The Curious Case of Mental Health Budgeting in New York

This article argues that the adverse impact of Medicaid on state budgets alleged in various public debates has been overstated, in some measure because of the inaccurate and misleading manner in which Medicaid expenditures are appropriated in state budgeting systems. Data on Medicaid and mental health spending in the state of New York is used for analysis. The first section provides a Medicaid spending and budgeting background. The second section discusses Medicaid and mental health in New York. The third section describes actual budgeted spending for mental health in New York, and the final section provides a discussion and concluding comments.     

Non-monetary obstacles to medical care: Evidence from postpartum contraceptives

We use changes to Medicaid immediate postpartum policy to test whether non-monetary costs are meaningful obstacles to health care. Medicaid in several states currently covers long-acting reversible contraceptives (LARCs, including IUDs and implants) immediately following delivery of a child, eliminating much of the time-cost and stress associated with obtaining a LARC. Postpartum LARCs can reduce unintended and short-interval pregnancies, which are associated with adverse neonatal outcomes. Births that occur in Catholic-owned hospitals are an ideal control group, because these hospitals are prohibited from offering family-planning services, including LARCs. Using difference-in-differences and individual-level administrative data from Louisiana and New York, we find eliminating non-monetary obstacles increases take-up of a high-value and highly effective form of contraception. Additionally, we find no evidence of crowd-out of outpatient LARCs.     

Immigrant Engagement in Participatory Budgeting in New York City

Participatory Budgeting (PB) is a welcome experiment in participatory democracy in New York City (NYC), one that could produce greater civic engagement of traditionally marginalized groups and more equitable resource distribution. By engaging immigrants, PB aims to affirm and elevate their voices, help develop their civic capacities, and promote their political participation and community empowerment. During the past four years, participation by immigrants (foreign-born residents) in New York City’s PB process (PBNYC) has steadily increased, growing from nineteen to twenty-eight percent of all PB voters. Yet, immigrant participation lags compared to their numbers, with great variation among PB districts. Using a mixed methods approach that incorporates surveys of and interviews with immigrant community members, staff at immigrant serving community-based organizations, and City Council staff, this article aims to parse out the logistical and affective barriers to participation immigrants face in PB districts and how PBNYC’s design attempts to circumvent said barriers and facilitate participation. Ultimately, our study reveals a complex mix of promising practices and structural constraints involved in working toward PB’s “inclusive” and “equitable” aims.     

Let Them Eat Lunch: The Impact of Universal Free Meals on Student Performance

This paper investigates the impact of extending free school lunch to all students, regardless of income, on academic performance in New York City middle schools. Using a difference-in-differences design and unique longitudinal, student-level data, we derive credibly causal estimates of the impacts of “Universal Free Meals” (UFM) on test scores in English Language Arts (ELA) and mathematics, and participation in school lunch. We find UFM increases academic performance by as much as 0.083 standard deviations in math and 0.059 in ELA for non-poor students, with smaller, statistically significant effects of 0.032 and 0.027 standard deviations in math and ELA for poor students. Further, UFM increases participation in school lunch by roughly 11.0 percentage points for non-poor students and 5.4 percentage points for poor students. We then investigate the academic effects of school lunch participation per se, using UFM as an instrumental variable. Results indicate that increases in school lunch participation improve academic performance for both poor and non-poor students; an additional lunch every two weeks increases test scores by roughly 0.08 standard deviations in math and 0.07 standard deviations in ELA. Finally, we explore potential unintended consequences for student weight outcomes, finding no evidence that UFM increases the probability that students are obese or overweight. We also find no evidence of increases in average body mass index (BMI). Instead, we find some evidence that participation in school lunch improves weight outcomes for non-poor students. Results are robust to an array of alternative specifications and assumptions about the sample.     

The Use of Rental Housing Assistance by Immigrants in the United States and New York City

Abstract

The large influx of immigrants to the United States and New York City from poorer countries has sparked considerable debate as to whether immigrants are becoming a “public charge” to American society. Most arguments have centered around immigrants’ use of cash assistance programs. This article compares immigrants’ receipt of rental housing assistance with that of native‐born Americans.

Bivariate analyses reveal that immigrants, as a group, are no more likely than native‐born households to use any form of rental housing assistance. Indeed, in most instances immigrants are less likely than native‐born households to receive assistance, with two exceptions: immigrants who have been in the United States since 1970 and immigrants from the former Soviet Union in New York City. Multivariate analyses reveal similar results, except that immigrants who have been in the United States since 1970 are no more likely than other immigrants to receive housing assistance when we control for other factors.     

The Effect of Breakfast in the Classroom on Obesity and Academic Performance: Evidence from New York City

Participation in the federally subsidized school breakfast program often falls well below its lunchtime counterpart. To increase take‐up, many districts have implemented Breakfast in the Classroom (BIC), offering breakfast directly to students at the start of the school day. Beyond increasing participation, advocates claim BIC improves academic performance, attendance, and engagement. Others caution BIC has deleterious effects on child weight. We use the implementation of BIC in New York City (NYC) to estimate its impact on meals program participation, body mass index (BMI), achievement, and attendance. While we find large effects on participation, our findings provide no evidence of hoped‐for gains in academic performance, or of feared increases in obesity. The policy case for BIC will depend upon reductions in hunger and food insecurity for disadvantaged children, or its longer‐term effects.     

Housing Affordability and Health: Evidence From New York City

It is generally understood that households make tradeoffs between housing costs and other living expenses. In this article, we examine the relationship between health-related outcomes and housing-induced financial burdens for renters in one of the most expensive cities in the world, New York, New York. Drawing from the Housing Vacancy Survey for 2011, a representative survey conducted by the U.S. Census Bureau of more than 16,000 households in New York City, we estimate the effect of housing cost burden on the overall health of renters and the extent to which they have postponed various types of medical services for financial reasons. Results show that higher out-of-pocket rent burdens are associated with worse self-reported health conditions and a higher likelihood to postpone medical services for financial reasons. This relationship is particularly strong for those households with severe rent burdens. In addition, housing cost burden is equally or more important than other physical housing characteristics in explaining the variation in self-reported general health status and health care postponement. These findings are robust across specifications with different degrees of household, unit/building, and neighborhood controls, and among longstanding and newer renters. Our findings point to the importance of considering health-related outcomes when designing housing policies, and that housing subsidies should target both renters' out-of-pocket costs and place-based repair and maintenance.     

From Porto Alegre to New York City: Participatory Budgeting and Democracy

Because of its popularity, there is now a large literature examining how participatory budgeting (PB) deepens participation by the poor and redistributes resources. Closer examinations of recent cases of PB can help us to better understand the political configurations in which these new participatory democratic spaces are embedded, and articulate the conditions that might lead to more meaningful outcomes. Who participates? For whose benefit? The articles in this symposium, on participatory budgeting in New York City (PBNYC), highlight both strengths and challenges of the largest American PB process. They focus less on redistribution, more on the dimensions of the process itself and of PBNYC’s successful social inclusion, new dynamics between participants and local politicians, and the subtleties of institutionalization. The symposium also reminds us, however, that contestations over meaningful participation are on-going, and that of all of PBNYC’s multiple goals, equity has proven to be the most elusive.     

Turnout and weather disruptions: Survey evidence from the 2012 presidential elections in the aftermath of Hurricane Sandy

This paper examines the rational choice reasoning that is used to explain the correlation between low voter turnout and the disruptions caused by weather related phenomena in the United States. Using in-person as well as phone survey data collected in New York City where the damage and disruption caused by Hurricane Sandy varied by district and even by city blocks, we explore, more directly than one can with aggregate data, whether individuals who were more affected by the disruptions caused by Hurricane Sandy were more or less likely to vote in the 2012 Presidential Election that took place while voters still struggled with the devastation of the hurricane and unusually low temperatures. Contrary to the findings of other scholars who use aggregate data to examine similar questions, we find that there is no difference in the likelihood to vote between citizens who experienced greater discomfort and those who experienced no discomfort even in non-competitive districts. We theorize that this is in part due to the resilience to costs and higher levels of political engagement that vulnerable groups develop under certain institutional conditions.     

Growing Grassroots Democracy: Dynamic Outcomes in Building New York City’s Participatory Budgeting Program

Within five years of its launch, Participatory Budgeting in New York City (PBNYC) spread from four to thirty-one of New York’s fifty-one council districts, enabling city residents to directly allocate thirty-eight million dollars in public funds. During this period, PBNYC’s neighborhood-level forums remained largely unchanged, but, in order to sustain growth, administrative shifts altered the institution’s basic design. This article examines how and why this transition affected the degree of popular control afforded by PBNYC, specifically within its cross-district Steering Committee. Analysis of original interviews and organizational documents indicates that the transition brought important, if modest, gains but impeded aspects of community empowerment through bureaucratic resistance and imbalanced governmental-civil society roles. Key players responded by reforming PBNYC’s internal governance. This case sheds light on the factors that shape participatory institutions and their impacts, emphasizing the dynamic interactions between actors and the resulting gains and losses that aggregate toward longer term outcomes.     

Nativity differences in neighborhood quality among New York city households

Abstract

This article adds to the literature on locational attainment of immigrants by evaluating how immigrant households in New York City compare with native‐born households with respect to neighborhood characteristics. It also examines whether the relationship between immigrant status and neighborhood quality varies by race/ethnicity and place of birth.

Overall, foreign‐born households are more likely than native‐born households to live in neighborhoods with less access to medical care, higher rates of tuberculosis, and higher concentrations of poverty. Multivariate analyses reveal that all but one of these disadvantages disappear for foreign‐born households as a group. However, island‐born Puerto Ricans and immigrants—especially Dominicans, Caribbeans and Africans, and Latin Americans—are more likely to reside in lower‐quality neighborhoods than native‐born white households. Equally important, native‐born blacks and Hispanics are also disproportionately disadvantaged relative to native‐born whites, suggesting that a racial hierarchy exists in the locational attainment of households in New York City.     

Stigma and other determinants of participation in TANF and Medicaid.

We developed a conceptual framework to examine the association between stigma, enrollment barriers (e.g., difficult application), knowledge, state policy, and participation in the Temporary Assistance to Needy Families (TANF) and adult Medicaid programs. Survey data from 901 community health center patients, who were potential and actual participants in these programs, indicated that while images of the Medicaid program and its recipients were generally positive, stigma associated with welfare stereotypes reduced both TANF and Medicaid enrollment. Expectations of poor treatment when applying for Medicaid, enrollment barriers, and misinformation about program rules were also associated with reduced Medicaid enrollment. States that enacted strict welfare reform policies were potentially decreasing TANF participation, while states with more simplified and generous programs were potentially increasing Medicaid participation. The results suggest that the image of the adult Medicaid program remains tied to perceptions about welfare and provides guidance to policymakers about how to improve participation rates.