Understanding the Impact of Wisconsin's Birth Cost Recovery Policy on Black Families: Qualitative Findings from a Community-Engaged, Mixed-Methods Study

Background: Birth Cost Recovery is a policy that holds some unmarried, non-custodial fathers responsible for Medicaid costs at the time of delivery. Wisconsin is the top enforcer of Birth Cost Recovery in the United States, having collected $193 million between 2011 and 2023. Importantly, Birth Cost Recovery disproportionately affects Black families, who are more likely than non-Black families to access prenatal Medicaid and also experience among the worst pregnancy-related outcomes. While supporters of Birth Cost Recovery argue that this policy promotes paternal responsibility, others contend that Birth Cost Recovery causes financial strain, decreases paternal involvement, and leads to delays in prenatal care access. However, the true impacts of Birth Cost Recovery have been largely unstudied. In this community-engaged, mixed-methods study, we sought to understand how Birth Cost Recovery impacts the health and well-being of Wisconsin families while centering the perspectives of the Black families disproportionately affected by this policy.

Methods: We began this sequential mixed-methods study by holding individual qualitative interviews on Zoom with Black parents in Wisconsin who had a recent Medicaid birth (N=50). We recruited participants purposively through Facebook and university and community partners. Interview facilitators were trained in qualitative methods and led semi-structured, one-hour Zoom interviews with research participants who were compensated with $50 digital gift cards. We audio-recorded interviews which were then professionally transcribed. The research team then conducted reflexive thematic analysis to identify and interpret patterns related to Black families’ experiences with Birth Cost Recovery and the ways they view the policy as impacting their health and well-being and that of their family members. Along with obtaining university IRB approval, a community advisory board advised the research team on all research materials and procedures.

Results: We faced many challenges with recruitment, including fraudulent participation and difficulty reaching our target population. We worked with our community advisory board to address these challenges and implement research protocols to prevent fraudulent participation and improve recruitment efforts. Through reflexive thematic analysis, we identified themes related to confusion about the policy, relationship stress, and financial burdens. Specifically, we discovered that those impacted by Birth Cost Recovery commonly conflated it with Medicaid and child support and expressed confusion about within-family and across-county differences in Birth Cost Recovery processes. Stories about costs paid by multiple generations within a family highlighted how this policy can impact future generations and reproduce inequities. Participants situated their experiences with Birth Cost Recovery within the context of their broader experiences with multiple oppressive systems, sharing stories about birth traumas, racial bias from healthcare providers, and multifaceted financial stressors.

Discussion: Findings suggest that Birth Cost Recovery may reproduce structural inequities and create strained family relationships. This research highlights opportunities to clarify the purpose and reach of Birth Cost Recovery and improve community understanding of this policy. We will use these qualitative findings to inform survey development for the quantitative stage of this mixed-methods study, which will involve a natural experiment comparing experiences and outcomes in counties that did and did not recently discontinue their Birth Cost Recovery policy.