Article Title

The Effect of Hard-Stop Medicaid Payment Reform on Early Elective Deliveries

Publication Date



Medicaid payment reform, perinatal health


Background/Aims: We assessed the impact of Texas’s Medicaid payment reform for early elective delivery on clinical care practices and perinatal outcomes.

Methods: We used National Vital Statistics System data for the years 2009–2013, which contained birth certificate records from all U.S. states and the District of Columbia. Data were merged to the 2014-2015 Area Health Resource File, which provided information on county-level economic and primary care provider characteristics for the five years in our study. Our key outcomes included early elective deliveries (induced and cesarean sections combined as well as cesarean section only), gestational age, birth weight (total, low birth weight, very low birth weight, large for gestational age) and early nonelective deliveries. We employed a difference-in-differences strategy to isolate the effect of the hard-stop policy in Texas from unrelated underlying trends present in control states. Models were adjusted for characteristics of the delivery and mother, if a father was not present on the birth certificate, county-level economic and provider trends, state-specific time trends, state fixed effects and linear time trends.

Results: Relative to the control states, there were significant reductions in early elective inductions of labor among Medicaid deliveries in Texas, including reduced rates of cesarean births. Of Texas births paid by Medicaid, 11.2% were the result of early elective induction of labor prior to hard-stop legislation; after adjusting for changes in early inductions in comparison states, this share dropped by 1.1 percentage points (P < 0.001). Birth outcomes also improved for babies covered by Medicaid in Texas, with relative increases in average gestational age and average birth weight.

Conclusion: Findings from this study suggest that the Medicaid hard-stop policy in Texas was effective in reducing the rate of early elective deliveries among the Medicaid population. As a result, babies covered by this policy reached an older gestational age and greater gestational weight. Since Texas had one of the highest rates of early elective delivery prior to enacting hard-stop, we would expect that states with similar baseline rates also would have relatively large reductions in early elective delivery rates should they pass hard-stop legislation.




July 5th, 2016


August 12th, 2016