Anna Aizer

Public Health Insurance, Program Take-Up, and Child Health

Of the ten million uninsured children in 1996, nearly half were eligible for public health insurance (Medicaid) but not enrolled. In response, policy efforts to reduce the uninsured have shifted from expanding Medicaid eligibility to increasing take-up among those eligible. However, little is known about the reasons poor families fail to enroll or the consequences. Using a unique data set I find that information and administrative costs are important barriers to enrollment, especially for Hispanics and Asians. In addition, enrolling children in Medicaid before they get sick promotes the use of preventative care, reduces the need for hospitalization, and improves health.

Home alone: supervision after school and child behavior

As female participation in the labor force continues to grow in the US, so too does reliance on non-parental child care. However, the high cost of child care has impeded the ability of many working mothers to find sufficient child care for their children. As a result, as recently as 1998 over eight million children ages five to fourteen spent time without adult supervision on a regular basis in the US. I examine the effect of the lack of adult supervision after school on panel of school-age children using ordinary least squares and fixed effect estimation. I find that children with adult supervision are less likely to skip school, use alcohol or marijuana, steal something or hurt someone. These findings suggest that expanding after school or child care programs typically geared to preschool age children to accommodate more school age children may have important consequences for their human capital development and labor market outcomes later in life.

The intergenerational transmission of inequality: Maternal disadvantage and health at birth

Health at birth is an important predictor of long-term outcomes, including education, income, and disability. Recent evidence suggests that maternal disadvantage leads to worse health at birth through poor health behaviors; exposure to harmful environmental factors; worse access to medical care, including family planning; and worse underlying maternal health. With increasing inequality, those at the bottom of the distribution now face relatively worse economic conditions, but newborn health among the most disadvantaged has actually improved. The most likely explanation is increasing knowledge about determinants of infant health and how to protect it along with public policies that put this knowledge into practice.

DOES MANAGED CARE HURT HEALTH? EVIDENCE FROM MEDICAID MOTHERS

Most Americans are now in some form of managed care plan that restricts access to services in order to reduce costs. It is difficult to determine whether these restrictions affect health because individuals and firms self-select into managed care. We investigate the effect of managed care using a California law that required some pregnant women on Medicaid to enter managed care. We use a unique longitudinal database of California births in which we observe changes in the regime faced by individual mothers between births. We find that Medicaid managed care reduced the quality of prenatal care and increased low birth weight, prematurity, and neonatal death.

The Impact of Child Support Enforcement on Fertility, Parental Investments, and Child Well-Being

Increasing the probability of paying child support, in addition to increasing resources available for investment in children, also may alter the incentives faced by men to have children out of wedlock. We find that strengthening child support enforcement leads men to have fewer out-of-wedlock births and among those who do become fathers, to do so with more educated women and those with a higher propensity to invest in children. Thus, policies that compel men to pay child support may affect child outcomes through two pathways: an increase in financial resources and a birth selection process.

Poverty, Violence, and Health: The Impact of Domestic Violence During Pregnancy on Newborn Health

Two percent of women in the United States suffer from intimate partner violence annually, with poor and minority women disproportionately affected. I provide evidence of an important negative externality associated with domestic violence by estimating a negative and causal relationship between violence during pregnancy and newborn health, exploiting variation in the enforcement of laws against domestic violence for identification. I find that hospitalization for an assault while pregnant reduces birth weight by 163 grams. This sheds new light on the infant health production process as well as observed income gradients in health given that poor mothers are disproportionately affected by violence.

Maternal Stress and Child Outcomes: Evidence from Siblings

We study how maternal stress affects offspring outcomes. We find that in utero exposure to elevated levels of the stress hormone cortisol negatively affects offspring cognition, health, and educational attainment. These findings are based on comparisons between siblings that limit variation to short-lived shocks and controls for unobserved differences between mothers that could bias estimates. Our results are consistent with recent experimental results in the neurobiological literature linking exogenous exposure to stress hormones in utero with declines in offspring cognitive, behavioral, and motor development. Moreover, we find that not only are mothers with low levels of human capital characterized by higher and more variable cortisol levels but that the negative impact of elevated cortisol on their offspring is greater. These results suggest that maternal stress may play a role in the intergenerational persistence of poverty.

Love, Hate and Murder: Commitment Devices in Violent Relationships

Many violent relationships are characterized by a high degree of cyclicality: women who are the victims of domestic violence often leave and return multiple times. To explain this we develop a model of time inconsistent preferences in the context of domestic violence. This time inconsistency generates a demand for commitment. We present supporting evidence that women in violent relationships display time inconsistent preferences by examining their demand for commitment devices. We find that no-drop policies - which compel the prosecutor to continue with prosecution even if the victim expresses a desire to drop the charges - result in an increase in reporting. No-drop policies also result in a decrease in the number of men murdered by intimates suggesting that some women in violent relationships move away from an extreme type of commitment device when a less costly one is offered.

Got Health? Advertising, Medicaid and Child Health

Of the ten million uninsured children in 1996, nearly half were eligible for Medicaid, the public health insurance program for poor families, but not enrolled. In response, policy efforts to improve coverage have shifted to increasing Medicaid take-up among those already eligible rather than expanding eligibility. However, little is known about the reasons poor families fail to use public programs or the consequences of failing to enroll. The latter is of particular relevance to Medicaid given that children are typically enrolled when they become sufficiently sick as to require hospitalization. Using detailed information on Medicaid outreach, enrollment and hospitalization rates in California, I find that 1) information and administrative costs are important barriers to program enrollment, and 2) enrolling children in Medicaid before they require hospitalization leads to a more efficient allocation of health care resources and better health by promoting preventative ambulatory care over more expensive hospital based care.

ACCESS TO CARE, PROVIDER CHOICE AND THE INFANT HEALTH GRADIENT *

Poor women typically use different medical providers than the non poor – resulting in de facto segregation of the poor in separate hospitals. They also have worse birth outcomes. This holds even for poor women with full insurance through Medicaid and controlling for geographic location. In this paper we explore the causes and consequences of using different providers. We exploit an exogenous change in policy that occurred in California in the early 1990s that suddenly increased Medicaid payments to providers. We find that women with Medicaid began delivering in the same hospitals as those with private insurance, suggesting that lack of access was partly responsible for the segregation and the observed differences in health. However we find that individual choice, not just access, also matters. We find that Black mothers responded least to the increase in provider access afforded by the policy change, even though they benefited the most in terms of reduced neonatal mortality and fewer pre-term births.