Tiffany Green on How Charging Dads for the Medicaid Costs of Their Baby’s Birth Affects Child Support

Siers-Poisson [00:00:06] Hello and thanks for joining us for the Poverty Research and Policy podcast from the Institute for Research on Poverty at the University of Wisconsin, Madison. I’m Judith Siers-Poisson. For this episode, we’re going to be talking with Dr. Tiffany Green about a report that she coauthored about the effects of Medicaid birth cost recovery policies and child support outcomes in Wisconsin. There’s an ongoing debate about whether to strengthen or eliminate birth cost recovery, but there has been a lack of evidence on the effects of birth cost recovery on child support related outcomes. You’ll find a link to the full report in the show notes for this episode. Tiffany Green is an associate professor in the Departments of Population Health Sciences and Obstetrics and Gynecology within the School of Medicine and Public Health at the University of Wisconsin–Madison. She’s also an IRP affiliate. Tiffany, thanks for joining us today.  

Green [00:00:56] Thank you so much for having me, Judith.  

Siers-Poisson [00:00:59] Let’s start by defining what the term birth cost recovery means.  

Green [00:01:03] Yeah, of course. Birth cost recovery is interesting because most people have not heard of it, including myself. I had not heard anything about it before 2019 when I came back to Wisconsin, I started learning about this particular policy. Birth cost recovery is a policy that holds unwed fathers liable for Medicaid birthing costs. So let’s say that you have a partner or you have a baby’s parent that uses Medicaid during delivery. That means that the State can go after that person  — and hold the partner liable, rather, for part of the Medicaid proving costs.  

Siers-Poisson [00:01:41] And how common a practice is this in other states?  

Green [00:01:45] It is not a practice that is that common in other states. In fact, there are a handful of other states that practice it. But Wisconsin is the most prominent state that collects birth class recovery dollars somewhere on the order of millions of dollars per year.  

Siers-Poisson [00:02:01] So what are the goals that they’re hoping to accomplish here in Wisconsin or in that handful of states where birth cost recovery is enacted?  

Green [00:02:10] Well, from what I can gather, people who support birth cost recovery say it’s an important mechanism for making sure that fathers are liable for covering some of the costs that are associated with bringing a child into the world. Others have really invoked personal responsibility. And not to put too fine a point on it, it also helps to support the operations of child support in the counties.  

Siers-Poisson [00:02:35] I’m guessing there are some concerns about these types of programs. Can you share some of those concerns with us?  

Green [00:02:41] Yes. There’s also been some robust critiques of these programs as well. There have been a lot of folks like ABC for Health, one public interest law firm, that have spoken out against birth cost recovery. Some of the claims are that birth cost recovery can potentially impede pregnant people from going to prenatal care. If you know that the father of your child is going to be charged with some of the costs of prenatal care, you may delay if you’re on Medicaid. Some people have argued that it may affect some downstream outcomes like infant health. Others have talked about the disruption that it can make to families. And the reality is there is not a whole lot of research evidence on birth cost recovery, although the little that there is suggests that this policy has negative employment outcomes for fathers.  

Siers-Poisson [00:03:32] So let’s talk more about your research on birth cost recovery in Wisconsin. First of all, what are the mechanisms for how the program works here?  

Green [00:03:42] So when a person has Medicaid, or rather in our state Badger Care coverage for birth, the State or county can ask or it does ask a person to declare the father of their child. And in that way, when paternity is established, then a county can go after the father of the child for child support costs and birth cost recovery, which is part of that idea. Let’s say that you are a birthing parent, a mother or other person that has given birth. You may say, “Well, I don’t want to tell you who the father of my child is.” And in that case, once you are finished with the prenatal period of Badger Care, So that’s about six weeks or so, and let’s say you’re eligible for regular Badger Care, the State can kick you off the rolls if you do not declare the father of your child.  

Siers-Poisson [00:04:31] You mentioned a large dollar amount and I want to get into that more. But let’s look first at how many children, or maybe we should talk about how many dads have been involved or affected by this program.  

Green [00:04:43] Sure, in our particular study—and it’s hard to pin down exact numbers— but I can tell you about our particular study. We looked at birth cost recovery cases or people that were born on Medicaid between the period 2016 and 2021. And then our final sort of case made it that we had over 40,000 cases before 2020, and we had almost 18,000 cases from 2020 to 2021. So a fair amount of potential to be charged under this program.  

Siers-Poisson [00:05:16] And to give us some context, what are some of the average amounts maybe the dads are being expected to pay back and over what amount of time?  

Green [00:05:24] So what we find in our own study is that prior to 2020, the charges vary. There’s a wide variation in the amount of charges on average. We found that among the people that did receive a birth cost recovery order—and I want to clarify that the numbers that I was talking about before are Medicaid births so the potential population that could be charged. Of those that were charged, so about 35% in Dane County and about 27% elsewhere. The average order amount for birth class recovery was about $2,400 in Dane County and about $1,700 in other counties, on average.  

Siers-Poisson [00:06:05] You talked about this being administered at a county level, and it was at that county level that a natural experiment kind of presented itself. Can you explain what the circumstances were that gave you some very distinct data sets to work with?  

Green [00:06:20] Yes. So when I got here to Wisconsin, people started telling me about birth cost recovery. And one of the things that came up was that this program was under debate in both Madison and, or rather Dane County, and Milwaukee counties. And in both places, there was strong consideration of rescinding the program or not rescinding the program, but rather ceasing new collections for the program. And Milwaukee ended up deciding not to conduct birth cost recovery cessation. They continue to recover these funds. But Joe Parisi declared in his budget that he was not going to continue to collect new birth cost recovery funds. I want to clarify that Dane County still does back collections, but they do not collect new birth cost recovery funds and they have not done that since January 2020. And in economics, we call that a little bit of a natural experiment, because the fundamental problem with trying to assert that birth cost recovery has causal effects on outcomes is that some of the same characteristics like poverty that impact the probability that you’re going to be on birth cost recovery can also have effects on other outcomes as well. And we thought that this was an important way of trying to understand whether birth cost recovery really did have impacts on outcomes. Originally, our intention was to focus on health outcomes, but we realized that we needed different kinds of data to be able to do that and be able to speak to these health outcomes with integrity. So I can talk a little bit more about that at the end. But in this particular project, we focus on child-support related outcomes, which, to be very frank, was not really an original interest of mine. But I think over the course of this project it started to really come to me that this was a really important issue that needs to be addressed. I know that seems very obvious, but I’m a health economist. Child support was not something that I was really focused on. But this particular project and this particular problem really helped me to uncover a new interest in understanding how fathers are affected in these processes.  

Siers-Poisson [00:08:39] So you’re looking at Dane County, which stopped making new birth cost recovery orders and then the rest of the state that continued. Let’s look at some of those specific child-support related outcomes. And we mentioned this earlier, but let’s start with the establishment of paternity. What did you find?  

Green [00:08:57] So we didn’t find a lot of huge changes in establishment of paternity. And one of the tricky parts that I want to provide a caveat for, for your listeners is that, you know, a natural experiment, it’s always debatable whether it’s being a natural experiment. Because we were ready to do the project, and then came March 2020 and everything changed. And what I’m saying is that the COVID-19 pandemic has made this a little bit more challenging to assess. So I want to put that caveat around the results. But what I can say is that we found little to no changes in the actual establishment of paternity, which you might imagine would be delayed by the pandemic. But we didn’t find much evidence of that.  

Siers-Poisson [00:09:45] Another factor was whether there was an effect on the amount of child support orders and how much was owed. And then there’s the factor of levels of compliance with the orders. Did you find any connections there?  

Green [00:09:57] What do we find specifically? One, we do find that birth cost recovery cessation in Dane County, the only county where birth cost recovery was stopped or new birth cost recovery was stopped, rather, was associated with slight increases in the probability that any child support was owed and that’s both at 12 months after the child’s birth or 24 months after the child’s birth. What it was also associated with is not just that increase in owing, but an increased probability that the birthing parent would receive money. And that is what is really important, because remember, and I don’t know if I’ve clarified this before. Birth costs recovery funds do not go to children. They go to the counties and they go to the State. Those funds do not go to children. What we found is that when Dane County ceased birth cost recovery collection, more money got into the pockets of the birthing parent.  

Siers-Poisson [00:10:57] And what do you think the connection is there?  

Green [00:11:00] I think that once fathers did not have to pay funds to the county or the state, the money could be diverted to the actual children who, to be quite frank, need the money.  

Siers-Poisson [00:11:14] Let’s talk a little bit more about those dads. Do you have information in the data that you were using on what their economic status was? Because we know that the moms were on Medicaid. But what do we know about the dads?  

Green [00:11:26] So we don’t have information on whether the fathers were on Medicaid. Obviously, Medicaid almost exclusively caters to low-income folks assigned female at birth, women and children. Right. So the dads are not included there. What we do know is a little bit about the employment status of the fathers and what they made.  

Siers-Poisson [00:11:48] Were there any racial or ethnic differences that you could detect in this research as it applies to the dads?  

Green [00:11:54] Sure. We surprisingly found that the earnings of the father actually increased a decent amount for Black families and decreased for Hispanic families, but not for White families. And I should say specifically for the fathers. So a lot of these families aren’t necessarily where the parents aren’t together. But we did find that there was significant racial variation in that outcome. The reasons why we were not fully clear about and one of the reasons is because we’re using administrative data. Administrative data, especially the administrative data that’s available through IRP, is a really rich source of data for researchers because we can integrate data from child support, from employment records, all those other things. And that tells us something. What it doesn’t tell us is the mechanisms through which there might have been differences across racial groups.  

Siers-Poisson [00:12:47] Did you have any other insights into the dads by using, as you said, that rich administrative data core?  

Green [00:12:54] Yes. Again, we did find differences in the amount of child support that Black and White and Hispanic fathers were able to pay. But again, we weren’t able to find the reasons why. And that is definitely something that we would like to explore further in further research, because identifying racial inequities and differences is one thing, but understanding the “why” is what I think policymakers need to make decisions on how to move forward.  

Siers-Poisson [00:13:23] So overall, what conclusions did you draw as a result of this study, this research on birth cost recovery?  

Green [00:13:30] Sure, if I were to sum it up into “too long, don’t read” as the kids say, what we found is that birth cost recovery cessation in Dane County was linked to increases in child support received by birthing parents or mothers. It was also associated with increases in child support orders. So although fathers were more likely to have a child support order established, more money went into the pockets of the birthing parent and by extension, the child. We did find that these associations were not uniform by race, and specifically the greatest improvements in terms of funds received tended to be among Black families. We also found, not surprisingly, some improvements in child support compliance. So the policy in general overall seemed to redirect funds to the birthing parents and children. But this seemed to vary by race.  

Siers-Poisson [00:14:28] You mentioned earlier that the pandemic started right when you were kind of kicking off your research. Were there any other limitations or conditions that maybe made the study a little more difficult or made it hard for you to look at the elements that you wanted to?  

Green [00:14:44] Well, another thing besides the pandemic is that, as we all know, Dane County tends to be really different than other counties. And it was hard to really find an appropriate comparison county or set of counties for Dane County. And so if you read the report, we try to put that caveat and limitation in the report. We continue to examine varying methodological approaches to make sure that we are trying to compare apples with apples. So that’s one caveat that I want to emphasize with this work.  

Siers-Poisson [00:15:19] What do you see as the most important implications of this research for public policy and for policymakers based on what you’ve learned?  

Green [00:15:29] Yeah, with the caveats that I mention, because as researchers, we always like to be very careful and cautious in terms of making policy pronouncements and implications—that’s not our job. But I will say this. I think that this is part of a decision about what we value. There are people that value this idea of parental responsibility, and they believe that fathers paying into this system is important. However, if we think about the overall health and well-being of Wisconsinites, we have empirical evidence that this policy has damaging effects on employment for fathers. And it also clearly, by what we find, ceasing it helps to get more money into the hands of mothers and other birthing parents. So I think this is all about what policymakers decide is most important to them when it comes to the health and well-being of this state.  

Siers-Poisson [00:16:29] And as we wrap up, Tiffany, what further research would you like to do or see done on these issues?  

Green [00:16:35] Well, we have been very fortunate to be funded by the Wisconsin Partnership Program, and specifically, they funded me through the new investigator program to take a deep dive into how this particular policy affects Black families. Because of the nature of structural inequality and racism, Black people are more likely to face Medicaid once they are pregnant and birthing. And because of that, Black Wisconsinites are disproportionately exposed to birth cost recovery, are potentially exposed to this program. Because of this, we are conducting some mixed methods research to try to, one, understand from community perspectives. And I should say there are multiple Black communities in Wisconsin. There’s no one community. We’re trying to understand from the perspectives of Black families across the state, including burdening parents, i.e., mothers and other non-cisgendered people who are giving birth, and fathers to try to understand what their perspective is on birth cost recovery. After we do that, we’ll be working with our world-class Survey Center here at UW to do cognitive interviewing on a pilot survey that we’re developing. And we’re doing cognitive interviewing because we want to make sure that the survey questions are adequately capturing the experiences and the understandings of the people that we care about and we want to center which is Black, low-income families in the state of Wisconsin. And after that, the survey center will be conducting a pilot survey where we survey people in Dane and Milwaukee counties to try to understand the impacts, or potential impacts, that birth cost recovery cessation had on mental health and physical health and family-level outcomes.  

Siers-Poisson [00:18:20] Well, we’ll certainly look forward to hearing more about that further research. Tiffany, thanks so much for spending time with us today. It was really great to hear about your work.  

Green [00:18:30] Thank you for having me.  

Siers-Poisson [00:18:32] Thanks so much to Dr. Tiffany Green, associate professor in the School of Medicine and Public Health at UW-Madison. She joined us to discuss a report that she coauthored titled “Effects of Medicaid Birth Cost Recovery Policy Changes on Child Support Outcomes in Wisconsin.” You’ll find a link to the full report in the show note for this episode. And a note: the authors of this report are solely responsible for the content therein. The authors would like to thank the Wisconsin Department of Children and Families for the use of data for this analysis, but these agencies do not certify the accuracy of the analyses presented. The production of this podcast was supported in part by funding from the U.S. Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation. But its contents don’t necessarily represent the opinions or policies of that office, of any other agency of the federal government, or of the Institute for Research on Poverty. Music for the episode is by PoiDog Pondering. Thanks for listening.