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LETTER |
The authors are with the Center for Clinical and Genetic Economics, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC.
Correspondence: Correspondence should be sent to Damon Seils, Center for Clinical and Genetic Economics, Duke Clinical Research Institute, PO Box 17969, Durham, NC 27715 (e-mail: damon.seils{at}duke.edu).
We read with concern the conclusion of Joyce et al. that the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) had little effect on perinatal health care use among foreign-born Latinas.1 We are particularly concerned about whether the data can be interpreted clearly enough to support this conclusion. Also, regardless of the findings, we wonder about the relevance of this study to our understanding of welfare reform's impact.
First, the authors sought to discern the effects of PRWORA on foreign-born Latinas' perinatal health care use. Yet the broad category "foreign-born Latinas" does not accurately reflect the population affected by PRWORA—noncitizen Latinas who were admitted to the United States after August 1996 and who sought Medicaid coverage for nonemergency care during their first 5 years in the country. The sample most likely did not include all members of the population of interest, and it definitely included people not in the population of interest, making it difficult to determine PRWORA's effect on the appropriate group.
Second, the authors' conclusion might have been justified if it had been based on a larger number of locations. Yet Joyce et al. studied only 3 locations, and California and New York City had effectively nullified the impact of PRWORA. We appreciate the difficulty of obtaining high-quality data, but we feel strongly that researchers should evaluate whether the quality of their data is such that it would be better to withhold premature conclusions. An alternative approach would have been to measure PRWORA's effects on long-term resource reallocation, especially more than 2 years beyond the act's implementation.
Finally, we are concerned that PRWORA's effects on perinatal health outcomes might be misinterpreted as representative of effects on other health outcomes. As Joyce et al. acknowledge, hospitals generally facilitate Medicaid applications in obstetric cases. Also, it seems reasonable to expect that pregnant women would be more likely than others to receive aid that would offset losses in public assistance. We wonder how the findings might have differed had the authors conducted their comparison using, say, noncitizen Latino men with coronary disease.
Whether this was the authors' intention or not, the article could be interpreted by some as supporting the idea that PRWORA has not harmed health care. Such an interpretation would be ill advised, given the grossly defined sample, the selection of locations that (except for one) did not implement the eligibility provisions of PRWORA, and the selection of a condition that is less vulnerable than others to changes in federal funding. With these considerations in mind, it is unclear what one could conclude from this research.
References
1.
Joyce T, Bauer T, Minkoff H, Kaestner R. Welfare reform and the perinatal health and health care use of Latino women in California, New York City, and Texas. Am J Public Health. 2001;91:1857–1864.
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