Post-ACA, More Than One-Third Of Women With Prenatal Medicaid Remained Uninsured Before Or After Pregnancy

Since the early 1990s, the Medicaid program has played an important role in providing insurance coverage for pregnant women with low incomes in the United States.^1,2 In 2018 the program covered 43 percent of births nationwide.³ Pregnancy-related Medicaid coverage is available to women with incomes up to 200 percent of the federal poverty level in most states, and several states offer even more generous eligibility.⁴ Because pregnancy-related Medicaid eligibility is almost always more generous than eligibility for other adults, many women with low incomes not otherwise eligible for Medicaid gain coverage during their pregnancies but then lose that coverage sixty days after delivery, when their pregnancy-related eligibility expires.² During 2005–13, for example, 65 percent of women who had their deliveries paid for by Medicaid were uninsured for at least one month during their pregnancy, and more than half were uninsured at some point in the six months after delivery.⁵ For immigrant women, uninsurance before or after pregnancy may also reflect Medicaid eligibility restrictions, which bar noncitizen adults from Medicaid eligibility if they lack documentation or if they have five or fewer years of lawful residence in the US.^6–8

The Affordable Care Act (ACA) provided new coverage options, starting in 2014, for adults with low incomes, including Medicaid expansion for adults with incomes up to 138 percent of poverty in some states and, for higher-income adults, availability of federally subsidized Marketplace coverage for adults with incomes up to 400 percent of poverty. Numerous studies have tracked changes in Medicaid coverage and uninsurance under the law for women of reproductive age and mothers at various points relative to pregnancy.^9–15 Specifically, the ACA Medicaid expansion has reduced uninsurance among women of reproductive age overall,^10,11 and particularly among new mothers in the year after delivery.¹² Expansion has also increased preconception and postpartum Medicaid coverage.^13–15 Although these studies did not find a significant impact of Medicaid expansion on uninsurance among women with low incomes just before pregnancy,^13,14 Jamie Daw and colleagues found that it was associated with a 28 percent reduction in churning between insurance and uninsurance throughout the perinatal period.¹⁶

Insurance coverage during the periods before (preconception) and after (postpartum) pregnancy has the potential to improve women’s health.^17,18 Preconception coverage can help women prevent unintended pregnancies and may improve management of chronic conditions before women become pregnant, which may ultimately lead to better maternal and infant birth outcomes.¹⁷ Importantly, the expansion of Medicaid eligibility under the ACA not only increased coverage and reduced churn but has also improved other outcomes among women and mothers. For example, the ACA Medicaid expansions improved access to care, increased use of health services, and led to better self-reported health among women of reproductive age, which could help women ensure a healthy start to their pregnancies.^11,14 Rebecca Myerson and colleagues also found improvements in several specific measures of preconception health, including folic acid intake and preconception health counseling, among a sample of new mothers.¹⁴ After delivery, postpartum coverage can also improve chronic condition management and increase access to care needed to recover from birth, potentially preventing late maternal deaths and improving overall health and well-being for mothers and their children.¹⁸ Stacey McMorrow and colleagues found increases in postpartum access to care and reduced problems affording care among new mothers after the major ACA coverage provisions,¹⁹ and Erica Eliason further found that the ACA Medicaid expansion was associated with reductions in maternal mortality.²⁰

Despite significant improvements under the ACA, however, churning into and out of coverage and between types of coverage persists,²¹ many women remain uninsured before and after their pregnancies,^9,14 and those who are uninsured face significant health problems. For example, a recent analysis documented obesity, cesarean deliveries, gestational diabetes, pregnancy-related hypertension, and depression—all conditions that require ongoing monitoring and care—among women who lost Medicaid coverage and became uninsured in the postpartum period.²² Moreover, the US continues to have the highest maternal mortality rate among developed countries, along with large and persistent racial inequities.^23,24

Several federal and state efforts have targeted the postpartum period, with proposals to extend pregnancy-related Medicaid coverage for up to a year postpartum, as a third of all pregnancy-related deaths occur within a year after birth.²⁵ Recent analysis has estimated that such provisions could benefit 123,000 new mothers uninsured during the year after pregnancy annually, who would become newly eligible for Medicaid or Children’s Health Insurance Program coverage through a postpartum extension.²⁶ But given the importance of preconception health and ongoing preconception uninsurance in the post-ACA era, it is important to consider policies that can address coverage gaps throughout the perinatal period.¹⁴ Further take-up of ACA Medicaid expansion, for example, could reduce both preconception and postpartum uninsurance, particularly because states that have not yet expanded Medicaid have even lower eligibility thresholds than the pre-ACA thresholds in expansion states.⁴

To better understand how different Medicaid policies may address the remaining barriers to coverage surrounding pregnancy among women with low incomes, we focus on a sample of women who had their prenatal care covered by Medicaid. In this sample of new mothers, we consider whether women were uninsured just before pregnancy, shortly after pregnancy, in either period alone, or in both periods. We further document the health status of women with prenatal Medicaid coverage who experience uninsurance during the perinatal period to provide insights on the potential benefits of expanding coverage to these women. Although changes in coverage and churn under the ACA have been well documented by other studies,^12–14,16 understanding which women continue to experience uninsurance surrounding pregnancy and when in the perinatal period uninsurance occurs can inform future policies aimed at improving maternal and child health beyond the ACA.

Study Data And Methods

Data

We used data from the Pregnancy Risk Assessment Monitoring System (PRAMS) in forty-three states (online appendix table 1).²⁷ PRAMS is a state-specific surveillance system of pregnancies resulting in a live birth and combines birth certificate data with a survey of new mothers.²⁸ We included women in twenty-seven expansion states and sixteen nonexpansion states. Because not all states are included in all years, we adjusted the PRAMS survey weights to reflect the number of years a state appears during the survey period. Nonexpansion states are those that never expanded during the 2015–18 period. We excluded data from years before expansion for Alaska (2015) and Louisiana (2015–16), classifying both as expansion states for the remaining years.

We focused on a sample of women ages twenty and older who gave birth in calendar years 2015–18 and who reported that their prenatal care was covered by Medicaid, representing 36.6 percent of new mothers in the data (appendix table 2).²⁷ We excluded teenagers from our analysis because they face different coverage options than adults through Medicaid and the Children’s Health Insurance Program. We considered the period 2015–18 to focus on patterns of uninsurance after the implementation of the major coverage provisions of the ACA and because pooling multiple years of data allowed us an adequate sample size to investigate differences in perinatal uninsurance rates by women’s characteristics.

Methods

We described patterns of uninsurance before and after pregnancy for women with Medicaid coverage for their prenatal care, using PRAMS measures of insurance coverage at three points: one month before conception; during prenatal care; and at the time of the postpartum survey, which is typically conducted two to six months after delivery. We refer to these three periods collectively as the perinatal period, and we excluded women who were missing insurance information in any of these periods.²⁹ Although PRAMS includes a measure of payer at delivery from the birth certificate, we limited our analysis to the three coverage measures collected directly from the PRAMS questionnaire for consistency of measurement.

We next examined how each of three perinatal uninsurance rates (preconception only, postpartum only, and both periods) varied across our sample by women’s race and ethnicity, the language of their survey, whether they are first-time mothers or mothers with previous births, and by their family income. We focused on patterns by race and ethnicity because several proposals to extend postpartum Medicaid coverage have been motivated by vast disparities in maternal mortality rates between Black women and their White and Hispanic counterparts.^30,31 We further considered survey language among Hispanic women because it may help identify women likely to face barriers to Medicaid eligibility because of immigration status if women completing the survey in Spanish are more likely than those completing an English-language survey to be recent immigrants.³² Similarly, we considered differences between women who already have children and first-time mothers because parents have historically had more generous eligibility for Medicaid outside pregnancy than childless adults, making first-time mothers particularly at risk for preconception uninsurance in nonexpansion states.

Finally, we examined differences in perinatal uninsurance patterns by income because of the importance of income in the variation in Medicaid eligibility between expansion and nonexpansion states and the variation in eligibility for pregnancy-related Medicaid eligibility versus other Medicaid pathways, such as parental Medicaid. We constructed two income categories using the PRAMS dollar-value income categories. Because these categories vary across states and survey years, we chose a threshold of $20,500 that could be consistently applied across states and years and classified women as having incomes above or below that amount. Throughout all of our analyses, we considered how patterns differed between the twenty-seven ACA Medicaid expansion states and the sixteen nonexpansion states in our sample. We assessed whether differences were statistically significant, using two-sided t-tests, and all analyses used PRAMS survey weights adjusted for the number of years the state was in our sample. Sample sizes for all subgroup analyses are in appendix table 2.²⁷

Limitations

Our study had several limitations. First, PRAMS is not nationally representative and does not include the same states in all years. Our sample states represent an estimated 7.5 million births in 2015–18, which is about 48 percent of the approximately 15.6 million births nationally in those years and does not include California.³ Second, PRAMS measures are self-reported and may suffer from recall or other biases. Third, we were unable to measure women’s income with more detail than broad categories and were unable to observe women’s immigration status or years of US residence, thereby preventing us from accurately assessing likely eligibility for Medicaid coverage under current or proposed policy. Finally, for four states in our sample that expanded Medicaid after January 1, 2014 (New Hampshire, Pennsylvania, Alaska, and Louisiana), expansion status might not apply to the preconception period for women who gave birth in the first year after expansion.³³

Study Results

Among new mothers who had their prenatal care covered by Medicaid in forty-three states during the period 2015–18, 26.8 percent were uninsured before their pregnancy, and 21.9 percent became uninsured in the two to six months after delivery (exhibit 1). These patterns varied sharply between states that did and did not expand Medicaid under the ACA. In expansion states, 17.3 percent of women with Medicaid-covered prenatal care were uninsured preconception, compared with 38.1 percent in nonexpansion states, and 10.0 percent of new mothers with prenatal Medicaid coverage became uninsured postpartum in expansion states, compared with 36.1 percent in nonexpansion states. About 34.5 percent of mothers with prenatal Medicaid coverage were uninsured at some point during the perinatal period, with mothers in nonexpansion states much more likely to have been uninsured (50.6 percent) than those in expansion states (21.0 percent).

SOURCE Authors’ analysis of 2015–18 Pregnancy Risk Assessment Monitoring System (PRAMS) data. NOTES The sample includes women ages twenty and older with a live birth in calendar years 2015–18 who reported that their prenatal care was covered by Medicaid in forty-three states with at least one year of PRAMS data during 2015–18. Differences in the rates of uninsurance for preconception, postpartum, and both preconception or postpartum are significantly different between expansion and nonexpansion states ($p<0.05$).

Among those who were ever uninsured during the perinatal period, about 36.4 percent were uninsured preconception only, 22.2 percent were uninsured postpartum only, and 41.4 percent were uninsured in both periods (exhibit 2). These patterns also differ by expansion status. In nonexpansion states, women who were ever uninsured were much more likely to be uninsured in both periods than women who were ever uninsured in expansion states. On the contrary, those who were ever uninsured in expansion states were much more likely to be uninsured preconception only, compared with women who were ever uninsured in nonexpansion states.

SOURCE Authors’ analysis of 2015–18 Pregnancy Risk Assessment Monitoring System (PRAMS) data. NOTES The sample includes women ages twenty and older with a live birth in calendar years 2015–18 who reported that their prenatal care was covered by Medicaid and that they were uninsured in the preconception or postpartum period in forty-three states with at least one year of PRAMS data during 2015–18. Differences in the rates of uninsurance for preconception only, postpartum only, and both preconception and postpartum are significantly different between expansion and nonexpansion states ($p<0.05$).

Perinatal uninsurance rates among women with prenatal Medicaid also varied by women’s characteristics (exhibit 3). In expansion states, differences by race and ethnicity were relatively modest for each measure of perinatal uninsurance, except for among Hispanic women who completed the survey in Spanish, who had the highest rates across all three uninsurance measures. This was especially pronounced for the share uninsured both preconception and postpartum, at 36.9 percent for Hispanic women who completed a Spanish-language survey compared with less than 7 percent for all other groups, including Hispanic women who completed an English-language survey (6.6 percent). These patterns may, in part, reflect Medicaid eligibility rules that restrict eligibility for women who are not US citizens.⁸

In nonexpansion states, Black women had the lowest rate of being uninsured in both periods (10.2 percent), and they also had relatively low rates for preconception-only and postpartum-only uninsurance. As in expansion states, Hispanic women in nonexpansion states who completed the survey in Spanish had the highest rate of being uninsured in both periods (54.0 percent), but in these states Hispanic women who completed the survey in English also had much a much higher rate of lacking both preconception and postpartum coverage (38.4 percent) than their White, Black, or other race counterparts. In both expansion and nonexpansion states, disparities in uninsurance between Black and White women were relatively modest compared with the gaps between Hispanic women and each of these groups.

First-time mothers were much more likely than their counterparts who were already mothers to be uninsured preconception only. In expansion states, 18.5 percent of first-time mothers were uninsured preconception only compared with 8.1 percent of mothers with other children. In nonexpansion states, both rates were somewhat higher, but the pattern was the same. These patterns emphasize the role of Medicaid in covering parents with low incomes even in the absence of an ACA Medicaid expansion. In addition, higher-income women were slightly more likely to be uninsured across all perinatal uninsurance measures in expansion states, whereas women with lower incomes were slightly more likely to be uninsured preconception only and in both periods in nonexpansion states. These patterns reflect the fact that those who could not qualify for Medicaid outside of pregnancy in expansion states had higher incomes than those in nonexpansion states.

Importantly, women with prenatal Medicaid coverage who experienced uninsurance at any point during the perinatal period were at risk for reduced access to and affordability of health care services outside of pregnancy, and these women reported health problems that could make this reduced access dangerous (exhibit 4). About 6.7 percent had preconception diabetes or hypertension, 12.2 percent had preconception depression, and almost 30 percent had obesity before pregnancy. In addition, about one-third had a cesarean delivery, 8.7 percent reported always or often feeling depressed, and 11.5 percent reported always or often lacking interest in activities in the postpartum period.

Discussion

Health insurance coverage and access to care before, during, and after pregnancy are important in promoting maternal and infant health.^17,18 Despite coverage provisions including Medicaid expansion and subsidized Marketplace coverage, we found that more than one-third of mothers with Medicaid for prenatal care were uninsured either before they became pregnant or in the two to six months postpartum in the years after ACA implementation. Fully half of women with prenatal Medicaid coverage in nonexpansion states experienced perinatal uninsurance. Even in expansion states, one in five women with prenatal Medicaid coverage experienced perinatal uninsurance, primarily in the preconception period. Consistent with prior analysis of racial disparities in uninsurance among new mothers, we observed the highest rates of uninsurance in both periods for Hispanic women, especially for those who completed the survey in Spanish.³⁴ Differences in uninsurance between Black and White new mothers with prenatal Medicaid coverage were more modest, suggesting that coverage expansions alone are unlikely to address the extreme Black-White disparities in maternal mortality.

The patterns of perinatal uninsurance documented here have important policy implications. Uninsurance only in the preconception period suggests that pregnancy and parenthood often bring women into the Medicaid program, through either new eligibility or new awareness of existing eligibility, and that once enrolled, these women are able to maintain insurance coverage. Women who are uninsured in the preconception period are least likely to benefit from a postpartum Medicaid extension but would benefit from outreach and enrollment efforts before pregnancy, particularly in expansion states, where more of these women are likely to be Medicaid eligible. In nonexpansion states, women experiencing preconception-only uninsurance could benefit from take-up of the ACA Medicaid expansion. In all states, outreach and enrollment efforts for subsidized Marketplace coverage could help women not eligible for Medicaid identify affordable coverage options.

Women experiencing uninsurance only in the postpartum period may have had access to public or private coverage before their pregnancy but were unable to maintain that coverage after enrolling in Medicaid for their pregnancy. This could reflect loss of employer coverage because of changes in employment after childbirth, issues transitioning between Medicaid eligibility categories such as from pregnancy-related eligibility to parental or expansion eligibility, or changes in income affecting Medicaid or Marketplace eligibility. An extension of postpartum Medicaid eligibility to a full year postpartum could help such women maintain coverage during the critical “fourth trimester”¹⁸ and provide a longer period to return to work and employer coverage or to manage enrollment paperwork and transition to parental Medicaid or Marketplace coverage.

Women experiencing uninsurance both preconception and postpartum indicates a lack of accessible public and private coverage options outside of pregnancy. These women may temporarily benefit from a postpartum extension but would likely need additional support to maintain coverage after it expires and before any subsequent pregnancy. To the extent that they are eligible for Medicaid or Marketplace subsidies but not enrolled, they may also benefit from increased outreach efforts. However, the high rates of uninsurance in both periods among Hispanic women completing a Spanish-language survey suggests that some of these women might not be eligible for Medicaid coverage outside of pregnancy because of eligibility policies barring noncitizen women from Medicaid for their first five years of US residence. Similarly, immigration restrictions likely bar some of these women from accessing subsidized coverage through the Marketplace. Moreover, recent changes to the public charge rule have created additional concerns for Medicaid-eligible women, resulting in some choosing to forgo this benefit for fear of future immigration consequences for themselves and their families.^35,36

Finally, women experiencing uninsurance during the perinatal period have health needs that require ongoing medical attention, including depression, diabetes, hypertension, obesity, and recovery from cesarean delivery. Without coverage, women may forgo needed care because of cost, which has implications for their health and, in the case of depression, the healthy development of their children.²² Policies to increase Medicaid coverage among women before and after pregnancy, including Medicaid expansion, postpartum Medicaid extension, and increased outreach and enrollment, have the potential to improve women’s self-reported health and increase the use of needed preconception and postpartum health services.^11,14 By improving women’s health outside of pregnancy, these policies can help women maintain good health throughout their lives and improve the health and well-being of their children.

ACKNOWLEDGMENTS

A prior version of this work was presented at the Association for Public Policy Analysis and Management 2020 Fall Research Conference (virtual), November 11–13, 2020. Financial support for this work was provided by the Robert Wood Johnson Foundation’s Policies for Action program. The authors are grateful for comments from Genevieve M. Kenney. They thank the Pregnancy Risk Assessment Monitoring System Working Group for providing access to the data used in this analysis: Tammie Yelldell (AL), Kathy Perham-Hester (AK), Enid Quintana-Torres (AZ), Letitia de Graft-Johnson (AR), Ashley Juhl (CO), Jennifer Morin (CT), George Yocher (DE), Tara Hylton (FL), Florence A. Kanu (GA), Matt Shim (HI), Julie Doetsch (IL), Brittany Reynolds (IN), Jennifer Pham (IA), Tracey D. Jewell (KY), Rosaria Trichilo (LA), Tom Patenaude (ME), Laurie Kettinger (MD), Hafsatou Diop (MA), Peterson Haak (MI), Mira Grice Sheff (MN), Brenda Hughes (MS), Venkata Garikapaty (MO), Emily Healy (MT), Jessica Seberger (NE), David J. Laflamme (NH), Sharon Smith Cooley (NJ), Sarah Schrock (NM), Anne Radigan (NY State), Lauren Birnie (NY City), Kathleen Jones-Vessey (NC), Grace Njau (ND), Ayesha Lampkins (OK), Cate Wilcox (OR), Sara Thuma (PA), Wanda Hernandez (PR), Karine Tolentino Monteiro (RI), Harley T. Davis (SC), Maggie Minett (SD), Ransom Wyse (TN), Tanya Guthrie (TX), Nicole Stone (UT), Peggy Brozicevic (VT), Kenesha Smith (VA), Linda Lohdefinck (WA), Melissa Baker (WV), Fiona Weeks (WI), Lorie Chesnut (WY), and the CDC Pregnancy Risk Assessment Monitoring System Team, Women’s Health and Fertility Branch, Division of Reproductive Health. The content is solely the responsibility of the authors and does not represent the official views of the Centers for Disease Control and Prevention.

NOTES

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