Medicaid Expansion Helped Close Coverage Gaps for Pregnant Women, New Study Finds

Medicaid expansion helped close coverage gaps for low-income women in the months before, during and after pregnancy, reducing the number of women who were uninsured during this critical time, new research published this month in Health Affairs found. The authors define “low-income” as a woman whose income is below 138% FPL, the eligibility limit for Medicaid expansion adult coverage.

The study compared the insurance coverage patterns of almost 50,000 low-income pregnant women who lived in 13 states and New York City that expanded Medicaid between 2012 and 2017, and six states that did not.  The researchers found that Medicaid expansion resulted in a 10.1-percentage-point decrease in churning between insurance and uninsurance during the perinatal period, which includes the period of the month before conception through the third month after birth.

This decrease was driven by a 5.8-percentage-point increase in the proportion of low-income women who were continuously insured throughout the perinatal period and a 4.2-percentage-point increase in churning between Medicaid and private insurance.

This improvement for women in the perinatal period adds to the mountain of evidence detailing the benefits of expanding Medicaid to all low-income adults for dozens of groups, including parents and other caregivers supporting young children. The uninsured rate for women of childbearing age is nearly twice as high in states that have not expanded Medicaid compared to those that have expanded Medicaid (16 percent v. 9 percent).

Continuous coverage is a critical tool in reducing maternal morbidity and mortality, a growing crisis in the United States. A separate study found that Medicaid expansion reduces maternal mortality, and the benefits of expansion in preventing maternal death are greatest for Black women, who are two to three times more likely to die in the year after childbirth than their white peers.

The Health Affairs study authors also make the case for Medicaid expansion as a way to reduce racial health disparities. Black and Hispanic women are more likely than non-Hispanic White women to lose coverage at some point during their pregnancy. They are also disproportionately affected by public charge restrictions and Medicaid work requirements, two policy developments that the authors point to as disproportionately harming Black and Hispanic women. CCF too has documented the specific harm that Medicaid work requirements and public charge rules pose to health coverage for Black and Hispanic mothers.

To better support postpartum women, policymakers in some expansion and non-expansion states are working to extend postpartum Medicaid coverage beyond the current 60-day statutory limit. Congressional lawmakers are also debating bills to extend coverage at the federal level. As CCF and a coalition of 279 national, state and local partners, pointed out in a letter to HHS Secretary Alex Azar this summer, approving state Medicaid waiver applications to extend postpartum coverage, such as proposals pending from Illinois, New Jersey, and Missouri, would also support health equity. California recently began covering postpartum women in Medicaid with a mental health diagnosis for one year beginning in August, using state-only funds.

These states are attempting to solve a widespread problem. Coverage churn during the perinatal period for low-income women is very common, affecting about 48 percent of all low-income women in Medicaid expansion states, and about 58 percent of low-income women in non-expansion states, the authors point out.

Given the complexities that families face during pregnancy and new parenthood—changes in income, employment or relationship status, among other things—expanding Medicaid, so that low-income women can remain enrolled in continuous Medicaid coverage before, during and after pregnancy, is an essential first step to putting young families on a healthy path.

Maggie Clark is a former staff member at the Georgetown University McCourt School of Public Policy’s Center for Children and Families.