Association for Public Policy Analysis & Management

Declining teen birthrates have been lauded as a positive policy development and their further reduction continues to be a desired policy goal. Despite their consistent drop from 36 births per 1000 teenagers in 1991 to 22 births per 1000 teens in 2002, the underlying causes of the decline remain unclear. This study investigates the potential effects of expansions to public health insurance eligibility on birthrates for teenagers age 15 through 17. Public health insurance expansions, which expand access to healthcare services, including reproductive healthcare, have been studied for their potential to affect birthrates of older women, but never specifically teen birthrates. I focus on the period from 1991 to 2002, which covers the first decade of steady declines in teen birthrates and the primary years of public health insurance expansions to children and teens. The resulting 50-state analysis includes 1,800 state-year-age groups. To measure public health insurance eligibility, this study uses the thresholds documented in the National Governors’ Association’s Maternal and Child Health Update reports, which record eligibility for children and teenagers for public health insurance through various means, including Medicaid, the State Children’s Health Insurance Program (CHIP), and state-funded programs. Eligibility thresholds are measured specifically for each year of age included in the analysis. Birthrates are calculated using National Vital Statistics data on births and Survey of Epidemiology and End Results (SEER) population estimates. To estimate the causal effect of public health insurance expansions on teen birthrates, I use a difference-in-differences model that exploits variation in public health insurance eligibility at the state, year, and age level. I also include state-level socio-demographic and policy covariates to control for unobserved factors related to those variables that may be correlated with public health insurance eligibility and teen birthrates. Results indicate that the effect of a 100 percentage point increase in the eligibility thresholds is a decline in teen births of 0.8 births per 1000 teens. Although small, this is a meaningful effect relative to the average birthrate of 30 births per 1000 teens over the period. Based on this finding, expansions to public health insurance programs are estimated to explain 9.3 percent of the nearly 40 percent decline in teen birthrates observed between 1991 and 2002. The estimates are robust to a number of specifications and sensitivity tests. These findings identify expanded public health insurance for adolescents as an important contributor to the decline in teen birthrates. They also highlight the importance of ensuring teenagers’ continued access to insurance coverage and reproductive healthcare to maintaining low teen birthrates.