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Despite belief WIC improves infant health, new study finds no positive or negative impact

New study is the first to account for two factors: women misreporting their WIC nutritional benefits and participation of the very poor in the program

Adfertising messages publicizing WIC vary by state.

Existing scientific literature suggests the U.S. government nutritional program known as WIC improves birth outcomes of children, but new research is unable to find either a positive or negative impact on infant health.

WIC, which serves 53 percent of all U.S. infants, is for low-income pregnant women and their young children under five who are at or below 185 percent of the federal poverty level. The program provides grocery store food vouchers or electronic benefit transfer cards for healthy and nutritious food, and free prenatal care and health and nutritional counseling.

But economist and study author Manan Roy, Southern Methodist University, Dallas, says women severely underreport having received WIC food vouchers, either because they fear the stigma or fail to recall participating; and also the “poorest of the poor” sign up for the programs. Ignoring either of those two factors could skew an analysis of WIC’s impact on infant health. This is the first study to simultaneously account for both.

Since the poorest of the poor have the most unfavorable attributes to begin with, the “true” effect of the program will be biased downwards. Measurement error in the reports also bias the “true” effect of WIC participation, Roy said.

“To my knowledge, this is the first study of WIC to account for both factors,” said Roy. “The results are striking and ought to serve as a note of caution and guide to future evaluations of the program. I am unable to conclude there exists a causal effect — positive or negative — of prenatal WIC receipt on birth outcomes, even if as few as 1 percent of eligible women misreport their participation.”

Based on these findings and the existing literature on program evaluation, Roy said, it would be ideal to have experimental data or at least some form of verification of program participation in nationally representative household surveys to accurately evaluate WIC’s impact. In the absence of such data, researchers should be aware of and accordingly account for both these problems using varied statistical methods. Roy’s study focused on birth outcomes of infants, and didn’t look at WIC’s effect on older eligible children or breastfeeding practices.

Existing literature notes underreporting without accounting for it, but suggests WIC improves birth outcomes
The evidence has strong implications, Roy said, since WIC caters to a special sub-population that is in maximum need of nutritious food, regular health check-ups and nutritional counseling.

Formally known as the Special Supplemental Nutrition Program for Women, Infants and Children, WIC is a $7.1 billion program of the U.S. Department of Agriculture. As of March 2012, WIC provides nearly 9 million women and young children an average of $46 a month each, according to the government. Recipients can buy milk, cheese, cereal, juice, fruits, vegetables, bread, beans and rice.

Driving research interest in WIC is the growing perception that early life conditions have a long-term impact on adult-life outcomes as well as the evidence that early life interventions yield higher returns than do later life remedial or compensatory interventions.

Prior studies evaluating the effectiveness of WIC are mostly based on household surveys. Researchers are aware, however, that the poorest of the poor enroll into programs like WIC and that an overwhelming number of women deny receiving the benefits when polled on household surveys. Existing scientific literature has consistently recognized the underreporting problem without accounting for it, but nevertheless suggests WIC improves birth outcomes of children, such as birth weight and gestation age.

New study accounts for poorest of the poor and underreporting receipt of benefits
“My contribution is that I account for both these problems simultaneously and conclude that it is difficult to be sure whether there is a positive or a negative effect of the program,” Roy said.

Roy used data on more than 4,000 9-month-old infants available from the Early Childhood Longitudinal Study-Birth Cohort, released by the National Center for Education Statistics, U.S. Department of Education.

In that study, women are interviewed when the child is 9 months old. They are asked whether they received WIC benefits while they were pregnant with the child. So, it is difficult to rule out an element of recall error in addition to the social stigma of “being on welfare,” Roy said.

“In this first step toward quantifying the consequence of misreporting, I find that even 1 percent of misreporting is sufficient to render inconclusive the evidence concerning WIC’s causal effect. Any greater degrees of misreporting will only worsen the situation,” she said.

Earlier research found low-income infants better off under public insurance
Roy presented her study, “Identifying the Effect of WIC on Infant Health When Participation is Endogenous and Misreported,” at the Southern Economic Association Annual Meeting, Washington, D.C., and in her dissertation, “Three Essays on the Effect of Public Policies on Infant and Adolescent Health.” The paper is available from IDEAS, a service of the Economic Research Division of the Federal Reserve Bank of St. Louis. Roy is a Ph.D. candidate in SMU’s Department of Economics.

The study follows earlier infant health research in which Roy analyzed data from the Early Childhood Longitudinal Study-Birth Cohort to compare private vs. public insurance and its impact on infant health. In that study, Roy found that among insured infants, those in low-income families are better off under government-provided Medicaid and CHIP than infants covered by private insurance, because public plans provide cheaper but comprehensive coverage.

Manan presented that study — “How well does the U.S. government provide health insurance?” — at the 2011 Western Economic Association International Conference, San Diego. — Margaret Allen

SMU is a nationally ranked private university in Dallas founded 100 years ago. Today, SMU enrolls nearly 11,000 students who benefit from the academic opportunities and international reach of seven degree-granting schools. For more information see www.smu.edu.

SMU has an uplink facility located on campus for live TV, radio, or online interviews. To speak with an SMU expert or book an SMU guest in the studio, call SMU News & Communications at 214-768-7650.

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UPI: Infants: Public insurance better, cheaper

The news wire service United Press International has covered the research of SMU economist Manan Roy, a doctoral candidate and adjunct professor in the SMU Department of Economics.

Roy analyzed new federal data about insured infants to compare public health insurance with private health insurance. Her analysis found that among the insured, infants in low-income families are better off under the nation’s government-funded public health insurance than infants covered by private insurance.

Read the full story.

EXCERPT:

SAN DIEGO, Dec. 8 (UPI) — Public health insurance coverage for infants is more comprehensive and costs less than private health insurance plans, a U.S. researcher found.

Study author Manan Roy, a Ph.D. student and an adjunct professor at Southern Methodist University in Dallas, said in the national debate over the Patient Protection and Affordable Care Act — which requires all Americans to have health insurance — it’s widely assumed private health insurance can do a better job than the public insurance funded by the U.S. government.

Infants covered under Medicaid and its sister program — CHIP — come mostly from lower-income families who are more likely to be unmarried, younger, less educated, poor and disadvantaged, while infants covered by private health insurance are mostly from white and are generally more advantaged, Roy said.

“Public health insurance gets a lot of bad press,” Roy said in a statement. “But for infants who are covered by health insurance, the government-funded insurance appears to be more efficient than private health insurance — and can actually provide better care at a lower cost.”

Read the full story.

SMU is a nationally ranked private university in Dallas founded 100 years ago. Today, SMU enrolls nearly 11,000 students who benefit from the academic opportunities and international reach of seven degree-granting schools. For more information see www.smu.edu.

SMU has an uplink facility located on campus for live TV, radio, or online interviews. To speak with an SMU expert or book an SMU guest in the studio, call SMU News & Communications at 214-768-7650.

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Public health insurance provides insured infants better, less costly care than private plans

Surprising result from first-of-its-kind study builds on earlier research that found public health insurance coverage is more comprehensive and costs less than private plans

In the fierce national debate over a new federal law that requires all Americans to have health insurance, it’s widely assumed that private health insurance can do a better job than the public insurance funded by the U.S. government.

But a first-of-its-kind analysis of newly available government data found just the opposite when it comes to infants covered by insurance.

Among the insured, infants in low-income families are better off under the nation’s government-funded public health insurance than infants covered by private insurance, says economist and study author Manan Roy, Southern Methodist University, Dallas. The finding emerged from an analysis that was weighted for the fact that less healthy infants are drawn into public health insurance from birth by its low cost.

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The finding is surprising, says Roy, because the popular belief is that private health insurance always provides better coverage. Roy’s analysis, however, found public health insurance is a better option — and not only for low-income infants.

“Public health insurance gets a lot of bad press,” says Roy. “But for infants who are covered by health insurance, the government-funded insurance appears to be more efficient than private health insurance — and can actually provide better care at a lower cost.”

Why?

“Private health insurance plans vary widely,” Roy says. “Many don’t include basic services. So infants on more affordable plans may not be covered for immunizations, prescription drugs, for vision or dental care, or even basic preventive care.”

The U.S. doesn’t have a system of universal health insurance. But the Patient Protection and Affordable Care Act signed into law by President Obama on March 23, 2010, requires all Americans to have health insurance. The act also expands government-paid free or low-cost Medicaid insurance to 133 percent of the federal poverty level.

“Given the study’s surprising outcome, it’s likely that the impact of national reforms to bring more children under public health insurance will substantially improve the health of infants who are in the worst health to begin with,” Roy says. “It’s likely to also help infants who aren’t low-income.”

Roy presented her study, “How Well Does the U.S. Government Provide Health Insurance?” at the 2011 Western Economic Association International Conference, San Diego. Roy is a Ph.D. student and an adjunct professor in SMU’s Department of Economics.

Study weighted to account for less healthy infants in public health insurance
A large body of previous research has established that insured infants are healthier than uninsured infants. Roy’s study appears to be the first of its kind to look only at insured infants to determine which kind of insurance has the most impact on infant health — private or public.

Roy found:

  • Infants covered by public insurance are mostly from disadvantaged backgrounds. Those under Medicaid and its sister program — CHIP — come mostly from lower-income families. Their parents — usually black and Hispanic — are more likely to be unmarried, younger and less educated. Economists refer to this statistical phenomenon — when a group consists primarily of people with specific characteristics — as strong positive or negative selection. In the case of public health insurance, strong negative selection is at work because it draws people who are poor and disadvantaged.
  • Infants on public health insurance are slightly less healthy than infants on private insurance. On average they had a lower five-minute Apgar score and shorter gestation age compared to privately insured infants. They were less likely to have a normal birth weight and normal Apgar score range, and were less likely to be born near term.
  • Infants covered by private health insurance are mostly from white or Asian families and are generally more advantaged. They are from higher-income families, with older parents who are usually married and more educated. Their mothers weigh less than those of infants on public insurance. This demonstrates strong positive selection of wealthier families into private health insurance.
  • Roy then compared the effect of public insurance on infant health in relation to private health insurance. To do that, she used an established statistical methodology that allows economists to factor negative or positive selection into the type of insurance. In comparing public vs. private insurance — allowing for strong negative selection into public health care — a different picture emerged.

“The results showed that it’s possible to attribute the entire detrimental effect of public health insurance to the negative selection that draws less healthy infants into public health insurance,” Roy says.

In fact, in a most striking revelation, allowing for a modest to significant amount of negative selection of infants into public health insurance, Roy’s findings suggest that among the insured population of infants, private health insurance is detrimental to child health.

“The real surprise with these findings is that despite a less healthy population — due to the negative factors created by poverty — public health insurance is actually improving the health of these infants,” Roy says.

Public health insurance provides more comprehensive benefits
The findings are less surprising upon deeper analysis.

  • A previous study by the nonpartisan Center on Budget and Policy Priorities sheds light on Roy’s research. That group found that public health insurance provides more comprehensive benefits than private insurance. For example, all children on Medicaid and CHIP receive preventive and primary medical care, inpatient and outpatient care, pediatric vaccines, laboratory and X-ray services, prescription drugs, immunizations, and dental, vision and mental health care coverage.
  • The Medical Expenditure Panel Survey collected by the U.S. Department of Health and Human Services found that on a per person basis, government-provided health insurance for children under 4 years old is cheaper on average compared to private health insurance plans.

“Enrollees in private health insurance can choose from a wide variety of plans,” Roy says. “Those who cut their costs by purchasing less coverage are reducing their access to quality care, including basic services like preventive care, prescription drugs, and vision and dental care.”

Roy says she can only speculate why infants from advantaged and disadvantaged families differ in their health outcomes. It’s possible that infants from families that are better off have access to better nutrition, a healthier lifestyle and possibly safer, cleaner neighborhoods than those from poorer backgrounds.

“Poor families and their infants may be subsisting on cheap food, for example, which tends to be fatty and less nutritious,” Roy says, “and that translates to worse health.”

Study relied on new U.S. government data on thousands of infants
Roy’s statistical analysis drew on data from more than 7,500 infants born in 2001. The data were the most recent available from the Early Childhood Longitudinal Study-Birth Cohort, released by the National Center for Education Statistics, U.S. Department of Education.

The Early Childhood Longitudinal Study follows children born in the United States from birth through the start of kindergarten. Children are from diverse socioeconomic and racial/ethnic backgrounds. Data were gathered from parents, teachers and providers of child care and early education.

Data collected cover children’s health, care, education and cognitive, social, emotional and physical development over time. Included are standard infant health measures like length, infant weight, five-minute Apgar score, and the number of weeks the child was in the womb, which is considered an indicator of birth weight.

Poor families living at or below 185 percent of the federal poverty level represented 49 percent of Roy’s data set.

Demand for public health insurance has increased during the past decade, says Roy, while demand for private insurance has declined. Specifically, between 1999 and 2009 there was an increase in the overall proportion of children under 3 years of age who were insured. Of those, the proportion covered by private insurance declined. The proportion covered by public health insurance increased.

Other researchers have firmly established that infants who are covered by health insurance have timely access to quality care, Roy says. Expanding access could reduce, for example, the number of infants born with low birth weight, which is associated with chronic medical diseases like diabetes, hypertension and heart disease in adulthood. Low birth weight also has been linked to lower average scores on tests of intellectual and social development.

The United States has the highest infant mortality rate among developed nations due to low birth weight and is the only industrialized nation without universal health insurance. The U.S. Supreme Court has agreed to hear a legal challenge to the Obama administration’s new law requiring everyone have health insurance. — Margaret Allen

SMU is a nationally ranked private university in Dallas founded 100 years ago. Today, SMU enrolls nearly 11,000 students who benefit from the academic opportunities and international reach of seven degree-granting schools. For more information see www.smu.edu.

SMU has an uplink facility located on campus for live TV, radio, or online interviews. To speak with an SMU expert or book an SMU guest in the studio, call SMU News & Communications at 214-768-7650.