Medicaid Expansion Narrows Maternal Health Coverage Gaps, But Racial Disparities Persist (Online Chartbook)

In This Report:

Introduction

The United States is experiencing a maternal mortality crisis. The nation has the highest maternal mortality rate of any industrialized country in the world.1  More than 750 women died of maternal causes in the United States while pregnant or within 42 days after the end of pregnancy in 2019.2 The same year, Black women had the highest maternal mortality rates of any identity (44 deaths per 100,000 live births)–2.5 times the rate for non-Hispanic white women and 3.5 times the rate for Hispanic women, data from the Centers for Disease Control and Prevention show.3

Figure 1. Change in Maternal Mortality Rate, 2018-2019


Chart 1. Uninsured Rate for Women of Childbearing Age (18- 44) by Expansion Status, 2019

While no one policy change can solve this crisis, Medicaid expansion is an effective strategy that has been shown to support the health of women of childbearing age and their children, with the greatest benefits for women and infants of color. Women in Medicaid expansion states had greater access to and utilization of health care before, during, and after pregnancy, and their children were also more likely to receive regular well-child visits.

A state’s decision to expand Medicaid has a profound effect on whether women of childbearing age have health coverage, which helps set the course for a healthy pregnancy and healthy baby. Women of childbearing age living in non-expansion states had an uninsured rate more than twice as high (19 percent) as women who lived in expansion states (9.2 percent) in 2019.4


Chart 2: Annual Uninsured Rate for Women of Childbearing Age (18-44), 2013-2019


Overall, between 2013 and 2019, the uninsured rate for women of childbearing age fell by 8.2 percentage points, from 21 percent in 2013 to 12.8 percent in 2019. This was greater than the decline for adults under age 65 during the same period.5


Chart 3: Uninsured Rate for Women of Childbearing Age (18- 44) by Poverty Level, 2013-2019

Medicaid expansion had the greatest impact in reducing uninsured rates for the lowest income women between 2013 and 2019, cutting their uninsured rate by more than 13 percentage points. However, this same group, those earning 0-137% FPL, still had the highest uninsured rate of any income group.


Chart 4: Percentage Point Change in Uninsured Rate for Women of Childbearing Age (18-44), 2013-2019


Uninsured rates in all states declined precipitously after the ACA’s coverage expansions began in 2013, due to the ACA’s “welcome mat effect” and new availability of Marketplace coverage.6 States that expanded Medicaid saw the steepest declines in the uninsured rate for women of childbearing age. The top 11 states with the largest declines were states that expanded Medicaid. New Mexico, West Virginia, and Kentucky saw decreases of more than 15 percentage points in the uninsured rate during this period.


Chart 5: Uninsured Rate for Women of Childbearing Age (18- 44) by Expansion Status and Race, 2019


Table 1: Uninsured Rate for Women of Childbearing Age (18- 44) by Expansion Status and Race, 2019


Table 2: Uninsured Rates for Women of Childbearing Age in Non-Expansion States Compared to Expansion States (View in full screen)


Medicaid expansion is beneficial for women of all racial identities. In expansion states, women who identified as Black, white, or “some other race” all had uninsured rates that were half of those of women with concordant racial identities in non-expansion states. While this pattern varies slightly by non-expansion state, the disparities are still clear. In Florida, for example, both Black and White women are more than twice as likely as their peers in expansion states to be uninsured.


Map 1: Uninsured Rate for Women of Childbearing Age

Click on the buttons below to view the uninsured rate for women of childbearing age by race.


States in the south generally had higher than average uninsured rates for all women of childbearing age. Sorting uninsured rates by race reveals unique geographic patterns, such as unusually high uninsured rates for Asian American/Pacific Islander women in Louisiana and Arkansas and lower than average uninsured rates for Black women in the Mid-Atlantic states.


Chart 6: Uninsured Rate for Women of Childbearing Age (18- 44) by Expansion Status and Ethnicity, 2019


The uninsured rate for women of childbearing age who identified as Hispanic/Latina in expansion states was also half the rate of Hispanic/Latina women in states that had not expanded Medicaid.


Map 2: Disparity in Uninsured Rate for Latina Women of Childbearing Age (18-44), 2019


Both expansion and non-expansion states have stark differences in uninsured rates by ethnicity between women who identify as Hispanic/Latina and those who do not.7 For instance, in Maryland and Minnesota, which have both expanded Medicaid, the states have an overall uninsured rate for women of childbearing age well below the national average, at 8.4 percent and 6.4 percent uninsured respectively. Yet in both states, Hispanic/Latina women had much higher uninsured rates than women who identified as non-Hispanic in 2019—five times as high in Maryland and four times as high in Minnesota. Wisconsin and Tennessee, which have not expanded Medicaid and have higher overall uninsured rates, had similarly wide disparity gaps.

The data makes clear that Medicaid expansion is an essential first step to ensure all women of childbearing age have a path to coverage, but there are other compounding factors that may contribute to higher uninsured rates for specific racial and ethnic groups. Variations in citizenship status contribute to higher uninsured rates among Latinas overall, since undocumented immigrants are ineligible for coverage in most states, outside of some pregnancy-only coverage. Hispanic women’s lack of access to health coverage in recent years can also be attributed to public intimidation from the Trump Administration’s public charge rule, which had a documented chilling effect on people from immigrant communities, and depressed their willingness to engage with public benefits despite their eligibility.8 One in five adults in immigrant families with children (20.4 percent) reported that they or a family member avoided a public benefit such as SNAP, Medicaid or the Children’s Health Insurance Program (CHIP), or housing subsidies in 2019 for fear of risking future green card status and 10 percent of those without children avoided such a program, a recent report from the Urban Institute found.9

Back to report

  1. E. Declercq, & L. Zephyrin, “Maternal Mortality in the United States: A Primer,” The Commonwealth Fund (December 2020), available at https://www.commonwealthfund.org/publications/issue-briefreport/2020/dec/maternal-mortality-united-states-primer.
  2. D.L. Hoyert, “Maternal Mortality Rates in the United States, 2019,” National Center for Health Statistics (April 2021), available at https://www.cdc.gov/nchs/data/hestat/maternal-mortality-2021/E-Stat-Maternal-Mortality-Rates-H.pdf.
  3. Ibid.
  4. Expansion states are designated as such if enrollment began by the start of 2019. Maine and Virginia are included as expansion states. Idaho, Utah, and Nebraska implemented Medicaid expansion during calendar year 2020 and are included as non-expansion states. Missouri and Oklahoma plan to implement expansion in 2021 and are included as non-expansion states.
  5. Declercq and Zephyrin, Op. cit. (21).
  6. Declercq and Zephyrin, Op. cit. (21).
  7. Declercq and Zephyrin, Op. cit. (40).
  8. J.M. Haley, G.M. Kenney, H. Bernstein, D. Gonzalez, “One in Five Adults in Immigrant Families with Children Reported Chilling Effects on Public Benefit Receipt in 2019,” Urban Institute (June 18, 2020), available at https://www.urban.org/research/publication/one-five-adults-immigrant-families-children-reported-chilling-effects-public-benefit-receipt-2019.
  9. Ibid.

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