摘要：Objectives. This study analyzed changes in the financing of prenatal care and delivery, the use of prenatal care, and birth outcomes among foreign-born vs US-born Latino women following enactment of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) in August 1996. Methods. We used a pre–post design with a comparison group. The sample consisted of resident Latinas in California, New York City, and Texas who delivered a live infant in 1995 or 1998. Results. The proportion of births to Latinas that initiated prenatal care in the first 4 months of pregnancy increased for all foreign-born Latinas in California, New York City, and Texas between 1995 and 1998 (P < .05). Except for non-Dominicans in New York City, there was no increase in the proportion of low- or very-low-birthweight births among foreign-born vs US-born Latinas in the 3 localities between 1995 and 1996. Conclusions. There is little evidence from vital statistics in California, New York City, and Texas that PRWORA had any substantive impact on the perinatal health and health care utilization of foreign-born relative to US-born Latinas. The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 fundamentally altered federal law regarding immigrant eligibility for Medicaid and other public benefits to immigrants. All legal immigrants entering the country after August 22, 1996, except those in protected categories that include refugees and asylum seekers, were barred from receiving federal public benefits for at least 5 years. As a result, many immigrants became ineligible for Medicaid coverage of prenatal care. In states like California, New York, and Texas, the number of immigrants potentially affected by this bar was significant. In 1995, 44% of all births in California, 43% of all births in New York City, and 25% of all births in Texas were to foreign-born women. In California and New York City, over 60% of births to foreign-born women were financed by Medicaid (authors' tabulations, available from the corresponding author). Since states responded differently to the new withdrawal of federal eligibility and funds, immigrants' perceived and actual loss of eligibility varied by state. For example, California chose to use state funds to finance the prenatal care of immigrants who were newly ineligible for federally funded Medicaid; in addition, California continued to use state funds for prenatal care for the undocumented. New York opted not to provide Medicaid to immigrants who entered the United States after August 1996. However, owing to a long-standing federal court decision, 1 Medicaid eligibility for all pregnant women in New York remained intact, regardless of their immigration status. On February 27, 1997, the federal government filed a motion to vacate this order, but it was denied in district court on January 19, 2000. In Texas, unlike in California, elected officials chose not to use state funds to replace the funds withdrawn by the federal government for prenatal care of Medicaid-eligible immigrants. This decision was implemented only 1 month after the passage of PRWORA (Texas Department of Human Services, unpublished data, 1996). The fear and confusion in the immigrant communities engendered by PRWORA has been widely reported, although the behavioral consequences of that concern have not been assessed. 2– 6 A study by researchers at the Urban Institute reported large drops in Medicaid coverage among immigrants in Los Angeles County in the wake of welfare reform despite there being no change in their eligibility and no similar decline among citizens. 7 In New York City, there have also been reports of a substantial increase in the number of women who were awarded, but did not collect, food coupons under the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in neighborhoods with large numbers of births to foreign-born women. 8 Finally, focus groups in California, New York, and Texas indicate that extensive misinformation and confusion exists. 9, 10 How much of the decline in the use of public benefits documented in these reports represents statewide trends is unclear. Moreover, there are few data to demonstrate adverse clinical outcomes among communities most likely to perceive or experience a change in access to primary care following federal or state initiatives. We therefore undertook this study to discern the effect of the new law on the perinatal health and health care utilization of Latino women. If welfare reform makes foreign-born women ineligible for, or fearful of seeking, publicly provided health insurance, then we may observe an increase in the percentage of births to foreign-born women that are uninsured, a decrease in early initiation of prenatal care, and an increase in adverse birth outcomes. To test this hypothesis, we used birth certificates from California, New York City, and Texas to characterize changes in perinatal outcomes among foreign-born vs US-born Latinas between 1995 and 1998. Specifically, we compared changes in the financing of births (Medicaid and self-pay), prenatal care utilization (early initiation of care and prenatal visits), and birth outcomes (low birthweight, very low birthweight, and preterm delivery) between US-born and foreign-born Latinas from 1995 to 1998.
