Date of Award

Spring 8-1-2018

Degree Type


Degree Name

Doctor of Philosophy (PhD)



First Advisor

James Marton

Second Advisor

E. Kathleen Adams

Third Advisor

Charles Courtemanche

Fourth Advisor

Thomas Mroz


This dissertation evaluates how publicly subsidized insurance programs impact fertility decisions, maternity services, and the health of children. I focus on two types of subsidized insurance: Medicaid, which is fully subsidized, and non-Medicaid subsidized insurance (NMSI) plans, which are partially subsidized. The first two chapters uses variation from the Affordable Care Act (ACA) to evaluate how eligibility for subsidized insurance affects birth related outcomes. The first chapter examines changes to the birth rate and the second chapter evaluates prenatal care, maternal health behaviors, delivery procedures, and birth outcomes. The third chapter focuses on Medicaid and explores how a shift to managed care affected care utilization for foster children.

The ACA greatly expanded subsidized health insurance opportunities for low-income childless women. This insurance provides better access to prescription-based contraception which could reduce the number of births. At the same time, subsidized insurance creates an income effect and lowers the price of childbirth for women who previously would not have qualified for Medicaid-paid pregnancies. In the first chapter, I use simulated eligibility measures to examine how Medicaid and NMSI policies impacted insurance enrollment and the birthrate for childless women from 2011 through 2016. My results indicate that expanding Medicaid had no significant effect on the birth rate, but that a 10 percentage point increase in NMSI eligibility increased the birth rate between 0.6% and 1.5%, depending on the age group.

The second chapter focuses on maternity related health care utilization and outcomes. While pregnancy-conditional Medicaid has covered maternity services for low-income pregnant women since the 1980s, new eligibility for subsidized insurance prior to conception via the ACA may improve timely prenatal visits and, in turn, pregnancy behaviors and outcomes. Additionally, women eligible for subsidized Marketplace plans but not pregnancy-conditional Medicaid gained access to subsidized maternity services. Overall, I find no changes in pregnancy and birth outcomes from the Medicaid expansion, but do find evidence of reduced smoking behaviors and increased breastfeeding arising from a higher share of women eligible for NMSI. Additionally, an increase in the share of women eligible for NMSI and not pregnancy-conditional Medicaid reduced the probability of Medicaid paid births.

The third chapter of this dissertation evaluates the impact of transitioning foster children from fee-for-service Medicaid coverage to Medicaid managed care (MMC) on outpatient health care utilization. A recent trend in state Medicaid programs is the transition of vulnerable populations into MMC who were initially carved out of such coverage, such as foster children or those with disabilities. There is very little empirical evidence on the impact of managed care on the health care utilization of foster children because of the recent timing of these transitions as well as challenges associated with finding datasets large enough to contain a sufficient number of foster children for such analysis. Using administrative Medicaid data from Kentucky, a retrospective difference-in-difference analysis compares the outpatient utilization of foster children transitioned to MMC in one region of the state to foster children in the rest of the state who remained in fee-for-service coverage. Results indicate that the transition to MMC led to a 4 percentage point reduction in the probability of having any monthly outpatient utilization, as well as a reduction in outpatient spending. This chapter is coauthored with James Marton, Aaron Yelowitz, and Jeffery Talbert and is published in Inquiry. It is reproduced here under the creative commons non-commercial license. When citing, please use the published version: Palmer et al. (2017).