Moms have another reason to smile this Mother’s Day: the uninsurance rate among mothers living with dependent children under the age of 19 fell 3.8 percentage points between 2013 and 2014, declining to 15.7 percent, the lowest rate observed since 1997.

According to a new Urban Institute analysis, uninsurance rates fell for mothers in almost all of the subgroups examined, with particularly large declines among young mothers, black and Hispanic mothers, and mothers living in the West. These gains followed the implementation of the major coverage provisions of the Affordable Care Act (ACA), which included an expansion of Medicaid, subsidies for coverage through the new marketplaces, health insurance market reforms, and penalties for going without insurance. In addition to the policy changes occurring under the ACA in 2014, the improving economy may also have contributed to these coverage gains.

While uninsurance rates dropped for mothers nationally, the data show a larger decline in uninsurance in the 26 states (including DC) that had adopted the ACA’s Medicaid expansion by early 2014 compared to the states that had not expanded – 4.8 versus 2.8 percentage points. In 2014, mothers living in nonexpansion states were nearly 1.7 times more likely to be uninsured than mothers living in states that had expanded Medicaid. Just over 60 percent of uninsured mothers lived in a state that had not expanded Medicaid in 2014, up from 54.7 percent in 2013.

Exhibit 1

Despite the good news about the gains in coverage relative to 2013, 5.9 million mothers were still uninsured in 2014. Just 26.6 percent of uninsured mothers said they had lacked coverage for less than a year; the rest said that they lacked coverage for longer or had never had insurance. Moreover, uninsurance rates remained over 30 percent for mothers with low incomes and those who were Hispanic, noncitizens, or who had not graduated from high school.

Exhibit 2

In 2014, over 60 percent of uninsured mothers had incomes at or below 138 percent of the federal poverty level. On the one hand, when asked why they did not have coverage, low-income uninsured mothers were less likely to cite cost as a reason than mothers with moderate and higher incomes. On the other hand, low-income mothers were more likely than other uninsured mothers to say that coverage stopped after pregnancy (24.2 percent compared to 10.3 percent) and to report a variety of other reasons for lacking coverage (20.7 percent compared to 15.2 percent).

Thus, while cost was the dominant reason for lacking coverage regardless of income, low-income mothers were more likely to attribute their uninsurance to other factors as well. Several of these explanations were associated with a loss of Medicaid coverage, either following pregnancy or for other reasons. This suggests that women may perceive their loss of eligibility for low-cost Medicaid coverage as the immediate cause of their uninsurance, even if the high cost of alternative coverage options was also a factor.

Exhibit 3

More recent data from the Urban Institute’s Health Reform Monitoring Survey on trends in coverage for parents indicate that there has likely been additional progress in reducing the number of mothers without insurance since 2014. Since the first half of 2014, five additional states have expanded Medicaid and there have been two more open enrollment periods for marketplace coverage. Enrollment in Medicaid and in federal and state health insurance Marketplaces continued to grow in 2015.

Yet in spite of these coverage gains, millions of mothers remain uninsured this Mother’s Day. Additional state expansions of Medicaid would help reach the disproportionate number of uninsured mothers who live in a nonexpansion state. Nearly 3.8 million nonelderly uninsured adults—including mothers and other parents as well as adults not living with dependent children—do not qualify for any financial assistance to obtain coverage because their states have not expanded Medicaid.

Reaching the 8.9 million uninsured nonelderly adults who already qualify for Medicaid or the Children’s Health Insurance Plan (CHIP), or for the most generous premium tax credits for purchasing coverage through the Marketplaces, would require more comprehensive outreach and enrollment efforts. Given the high rates of uninsurance among Hispanic mothers and those with less than a high school education, more assistance is needed to overcome language and health insurance literacy barriers. In addition, employing targeted enrollment strategies—such as enrolling parents based on children’s eligibility, which has been used in some states—may be a particularly effective way to reduce uninsurance among low-income mothers, especially in states that have expanded Medicaid under the ACA.

Moreover, the prevalence of coverage loss following pregnancy and job losses or changes highlights the risks of coverage interruptions that some women face in a complex insurance system with multiple coverage options. Maintaining continuous coverage during such transitions will require additional efforts to improve enrollment and renewal processes.

However, the increasing share of mothers with coverage is likely to have a significant effect on access to health care, ability to pay medical bills, and mental health. Children are also expected to benefit, since their coverage and access to care have been shown to improve when their parents have coverage. Increasing the number of mothers with insurance may also improve outcomes for children in other ways, such as by reducing maternal depression, which can affect parenting abilities.

Just over 15 percent of uninsured mothers reported moderate or severe psychological distress in 2014 and nearly 10 percent said they were in fair or poor health. According to tabulations of National Health Interview Survey data, uninsured mothers were 29 percentage points more likely than insured mothers to go without needed care in the previous year because it was not affordable, even after adjusting for differences in the characteristics of the two groups.

Together, these findings suggest that by expanding coverage and improving the health and financial stability of mothers and their families, the ACA may be contributing to a healthier, happier Mother’s Day. Perhaps when we toast moms on their special day in 2017, there will be even greater coverage gains to celebrate.