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Medicaid eligibility, prenatal care, and the outcome of pregnancy.

To the Editor.— The recent excellent article by Piper et al 1 documents the absence of improvements in use of early prenatal care, birth weight, or neonatal mortality with expanded Medicaid eligibility in Tennessee. This study and an accompanying editorial by Guyer 2 describe a variety of reasons for the lack of health status improvement with the removal of financial barriers to obtaining prenatal care. The results are actually not surprising, but clearly illustrate that policy-makers in government, public health, and medicine have overlooked a vital risk factor for low birth weight and neonatal morbidity and mortality: voluntary, deleterious maternal behavior. Indeed, behaviors such as cigarette smoking, alcohol consumption, illicit drug use, "junk food" nutrition, obesity, and adolescent pregnancy all affect the newborn's health. No amount of openended or expanded Medicaid funding can correct this. The data demonstrate that we have reached the point of diminishing returns, with funding directed