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Medicaid Expansions Improved Preconception Coverage for Low-income Women

Key findings

  • In a study of low-income women who gave birth between 2009 and 2015, preconception Medicaid coverage increased by 8.6% among women in states that expanded Medicaid coverage following passage of the Affordable Care Act (ACA)
  • Private insurance coverage decreased by 4.1% in expansion states relative to states that did not expand Medicaid coverage after the ACA passed
  • Switching from private insurance to Medicaid, once eligible, reduces the risk of frequent changes in insurance coverage and periods of being uninsured, which could prevent adequate prenatal care
  • In a subgroup analysis of women with prenatal Medicaid coverage, ACA Medicaid expansion was associated with greater continuity of Medicaid coverage from preconception to pregnancy

Research suggests that before the Affordable Care Act (ACA) was passed, low-income women of reproductive age were apt to have frequent changes in insurance coverage. Between 2005 and 2013, more than half of women who had Medicaid coverage in the month of delivery had experienced a change in insurance coverage or at least one month of uninsurance in the 12 months before delivery. This may have led to inadequate prenatal care.

An important component of the ACA was to give states the option of receiving federal support if they expanded their Medicaid programs to cover all nonelderly adults with incomes at or below 138% of the federal poverty level. Mark A. Clapp, MD, maternal fetal medicine fellow with the Deborah Kelly Center for Outcomes Research in the Department of Obstetrics and Gynecology at Massachusetts General Hospital, and colleagues report in Obstetrics & Gynecology that the ACA Medicaid expansions had beneficial effects on preconception insurance coverage for low-income women.

A Before and After Comparison

Dr. Clapp's team used the Pregnancy Risk Assessment Monitoring System database, which is administered by the Centers for Disease Control and Prevention, to find records on women with incomes ≤138% of the federal poverty level who delivered live infants between 2009 and 2015. They identified 30,495 women from eight states that expanded their Medicaid programs soon after the ACA was passed and 26,561 from seven states that did not.

The researchers compared the nonexpansion and expansion states with regard to changes in preconception insurance coverage from before the ACA was passed (prepolicy period, 2009–2013) to the year afterward (postpolicy period, 2015). The primary outcome was women's self-reported coverage in the month before conception, categorized as Medicaid coverage, uninsured, or non-Medicaid insurance coverage.

Changes in Preconception Insurance Coverage

The researchers found that the ACA Medicaid expansions were associated with significant increases in preconception Medicaid coverage and significant decreases in non-Medicaid insurance coverage:

Rates of Medicaid Coverage

  • Nonexpansion states: 30.8% prepolicy, 35.6% postpolicy
  • Expansion states: 43.2% prepolicy, 56.8% postpolicy
  • Result of adjusted regression analysis: Significant increase in Medicaid coverage in the expansion states by 8.6 percentage points, representing a 20% increase from the prepolicy baseline

Rates of Non-Medicaid Insurance Coverage

  • Nonexpansion states: 25.3% prepolicy, 30.5% postpolicy
  • Expansion states: 19.4% prepolicy, 19.7% postpolicy
  • Result of adjusted regression analysis: Significant decrease in non-Medicaid insurance coverage in the expansion states by 24.7 percentage points

Rates of uninsurance decreased similarly in the expansion and nonexpansion states.

In a subgroup analysis of women with prenatal Medicaid coverage, the researchers detected an increase in preconception Medicaid coverage by 9.8 percentage points, in expansion states relative to nonexpansion states. This increase represented a 21% increase from the prepolicy period.

The researchers infer that Medicaid expansion was associated with greater continuity of Medicaid coverage from preconception to pregnancy.

Benefits of Medicaid Versus Private Insurance

The researchers believe that private insurance crowd out, in which privately insured individuals switch to Medicaid once eligible, could be especially beneficial for pregnant women. Having to switch between insurance types is associated with access barriers and care delays that can interfere with planning a pregnancy and optimizing health before conceiving.

Furthermore, compared with private insurance, Medicaid coverage offers lower cost-sharing. In some states, it provides benefits such as social services, nutrition and transportation that may further reduce costs and other barriers to access.

8.6%
increase in preconception Medicaid coverage among women in states that expanded Medicaid coverage following passage of the Affordable Care Act (ACA)

4.1%
decrease in private insurance coverage in Medicaid expansion states relative to states that did not expand Medicaid coverage after ACA passage

Learn more about the Deborah Kelly Center for Outcomes Research

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