Public health officials in Massachusetts were surprised and concerned in 1984 to learn that for the first time in a decade, the statewide infant mortality rate had increased. Infant mortality, which includes deaths of all infants from the time of live birth to the first birthday, is widely recognized as an important and sensitive indicator of a population's health status and general well-being. Further examination of the birth and death data revealed that the death rate for African-American infants was twice the rate for Caucasian infants and that poor, minority and uneducated populations accounted for the bulk of the sharp increase in infant deaths.
In September 1984, the Task Force on Low Birth Weight and Infant Mortality was assembled to study the data and explain the sudden reversal in infant mortality. After months of deliberation, the task force concluded that concern about payment for prenatal and maternity services was the major barrier that prevented women from seeking early and continuous health care. Women and families that did not have health insurance were found to delay initiation of care, skip expensive laboratory tests and miss appointments rather than face high out-of-pocket costs. The primary recommendation of the task force was to urge that an entitlement program be developed for all pregnant women without insurance. The Massachusetts Legislature promptly acted on this suggestion and appropriated $6.1 million for FY 1986. After five months of planning, Healthy Start opened its doors for applications on December 2, 1985.
The purpose of the program is to improve birth outcomes by encouraging early and continuous comprehensive prenatal care. The cornerstone for the program is the philosophy that paying for services is only the first step in promoting healthy birth outcomes. Outreach, case management, client advocacy, community education, and a program entirely designed to be receptive to women in crisis, raise Healthy Start from simply a payment program to a comprehensive public health program.
Healthy Start pays for prenatal, delivery, and postpartum care, pharmacy, lab and pregnancy-related ancillary services and guarantees payment of inpatient services through another state mechanism. The program emphasizes case management and follow-up which is provided primarily by regionally based staff. Intake workers also provide extensive information and referral and emphasize comprehensive care for clients. Regional staff pay special attention to client follow-up and coordinating services.
The primary target groups are the low-income, working "near-poor." About 65 percent of Healthy Start clients have incomes that make them ineligible for Medicaid. Healthy Start has an upper income guideline of 200 percent of the federal poverty level and about 70 percent of uninsured women in Massachusetts meet this income guideline. Other subgroups include minorities, teens, non-English speaking and de facto immigrants. Program data indicate that these at-risk groups have been successfully enrolled in the program. In the first year of operation, while still in the start-up phase, Healthy Start enrolled 85 percent of all potentially eligible women.
The most important achievement to date has been to directly improve birth outcomes for women during the first year for the targeted high-risk groups. For the period July-December 1986, Healthy Start clients had a lower rate of low-birth weight infants than women without insurance or with Medicaid. Among minorities, teens, unmarried women and women without a high school diploma, Healthy Start had a lower rate of low-birth weight infants than women with private insurance. Healthy Start clients also had a lower rate of premature births than women without insurance or with Medicaid.