Medicaid Expansion Narrows Maternal Health Coverage Gaps, But Racial Disparities Persist

In This Report:

Key Findings

  • The U.S. has the highest maternal mortality rate of any industrialized country and the crisis is getting worse.[1] The burden weighs heaviest on Black women, who are more than twice as likely to die of pregnancy-related causes than the national average rate for all women, regardless of education level or other socioeconomic factors.[2] The majority of these deaths are preventable.[3]
  • A state’s decision on whether to expand Medicaid has a profound effect on women of childbearing age.[4] Women of childbearing age (age 18-44) who lived in non-expansion states were more than twice as likely to be uninsured (19 percent) than women living in states that had expanded Medicaid (9.2 percent) in 2019, and the trend extended across all racial and ethnic groups.
  • Medicaid expansion is associated with lower rates of maternal and infant mortality, with the greatest benefits for Black women and infants, studies have shown.[5] Expansion has also been associated with improvements in preconception health and utilization of preventive care, and supporting healthy development of parents and children together.[6]
  • In the years following the ACA coverage expansions, the United States made significant progress in reducing the uninsured rate for women of childbearing age and reached a historic low of 12.3 percent uninsured in 2016. But the nation changed course and the rate significantly increased to 12.8 percent by 2019. There were 384,000 more uninsured women of childbearing age in 2019 than in 2016. In 2019, 7.5 million women of childbearing age were uninsured.
  • Wide disparities in coverage persist between racial and ethnic groups within states, both in states that have expanded Medicaid and in states that have not. Women who identified as Hispanic/Latina in non-expansion states have the highest uninsured rates of any racial or ethnic group, with more than one-third, or 35.5 percent, reporting being uninsured in 2019 (see Table 1).[7]

Introduction

The United States is experiencing a maternal mortality crisis and has the highest maternal mortality rate of any industrialized country in the world.8 In 2019, more than 750 women died of maternal causes in the United States while pregnant or within 42 days after the end of pregnancy, data from the Centers for Disease Control and Prevention shows.9 The maternal mortality rate in 2019 for all women, at 20.1 deaths per 100,000 live births, was significantly higher than the rate for 2018, at 17.4 deaths per 100,000 live births (see Figure 1).10 The 2019 maternal mortality rate was the highest rate recorded by the CDC since the agency began tracking pregnancy-related mortality more than 30 years ago.11

Disaggregating the data by race, Black women had the highest maternal mortality rates of any group in 2019 (44 deaths per 100,000 live births), which was 2.5 times the rate for non-Hispanic white women and 3.5 times the rate for Hispanic women, the data showed.12 Previously between 2014 and 2017, Black women and American Indian/Alaska Native women consistently experienced the highest maternal mortality rates of any racial groups, which the CDC reports may be due to several factors, including structural racism and implicit biases.13 For instance, Black and American Indian/Alaska Native women are more likely to live in areas with limited access to maternity care, known as “maternity care deserts,” and report consistent experiences of racism while interacting with the health care system.14 These accumulated experiences of racism can contribute to toxic, unrelenting stress, which can interrupt the function of the immune, endocrine, and nervous systems, leading to chronic inflammation in the body.15 Among pregnant women, the effects of this toxic stress are felt by mothers and babies alike: multiple studies have shown that women who experienced racism and discrimination were more likely to have an infant born at low or very low birth weight.16

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

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. Research shows that Medicaid expansion is significantly associated with seven fewer maternal deaths per 100,000 live births relative to non-expansion states, with the greatest decreases in mortality rates among Black, non-Hispanic women and Hispanic women.17 Medicaid expansion has also been linked to declines in infant mortality, with the steepest declines for Black babies.18

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Endnotes

1D.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.
2Centers for Disease Control and Prevention, “Racial/Ethnic Disparities in Pregnancy-Related Deaths – United States, 2007-2016,” (February 2020), available at https://www.cdc.gov/reproductivehealth/maternal-mortality/disparities-pregnancy-related-deaths/infographic.html.
3N.L. Davis, A.N. Smoots, & D.A. Goodman, “Pregnancy-Related Deaths: Data from 14 U.S. Maternal Mortality Review Committees, 2008-2017,” National Center for Chronic Disease Prevention and Health Promotion (September 2019), available at https://www.cdc.gov/reproductivehealth/maternal-mortality/erase-mm/mmr-data-brief.html.
4Editor’s note: To maintain accuracy, CCF uses the term “women” when referencing statute, regulations, research, or other data sources that use the term “women” to define or count people who are pregnant or give birth. This includes self-reported data collected by the U.S. Census Bureau. Where possible, we use more inclusive terms in recognition that not all individuals who become pregnant and give birth identify as women. Available data included in this report does not capture information about pregnant people and people who give birth who do not identify as women.
5E.L. Eliason, “Adoption of Medicaid Expansion Is Associated with Lower Maternal Mortality,” Women’s Health Issues, 30: 147-152 (2020), available at https://www.sciencedirect.com/science/article/abs/pii/S1049386720300050.
6R. Myerson, S. Crawford, & L.R. Wherry, “Medicaid Expansion Increased Preconception Health Counseling, Folic Acid Intake, and Postpartum Contraception,” Health Affairs, 39: 1883-1890 (2020), available at https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2020.00106.
7We report the ACS category “some other race alone” and “two or more races” as “other.” Except for “other,” all racial categories refer to respondents who indicated belonging to only one race. The Census Bureau considers race and ethnicity two separate facets of a persons’ identity. Hispanic/Latina individuals can be of any race.
8 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-brief-report/2020/dec/maternal-mortality-united-states-primer.
9 Op. cit. (1).
10 Op. cit. (1).
11 “Pregnancy Mortality Surveillance System,” Centers for Disease Control and Prevention, https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm (accessed August 19, 2021).
12 Op. cit. (1).
13 Op. cit. (2).
14 J. Crear-Perry, S. Hernandez-Cancio, “Saving the Lives of Moms and Babies: Addressing Racism and Socioeconomic Influences,” National Partnership for Women and Families and National Birth Equity Collaborative (August 2021), available at https://www.nationalpartnership.org/our-work/resources/health-care/saving-the-lives-of-moms-and.pdf (accessed August 27, 2021).
15 A. Geronimus, et. al.,’Weathering’ and Age Patterns of Allostatic Load Scores Among Blacks and Whites in the United States,” American Journal of Public Health 96, 826_833, available at https://doi.org/10.2105/AJPH.2004.060749 (accessed August 27, 2021.
16 S. Hernandex-Cancio, V. Gray, “Racism Hurts Moms and Babies,” National Partnership for Women and Families and National Birth Equity Collaborative (August 2021), available at https://www.nationalpartnership.org/our-work/resources/health-care/racism-hurts-moms-and-babies.pdf (accessed August 27, 2021).
17 Op cit. (5)
18 Bhatt, C. and C. Beck-Sagué, “Medicaid Expansion and Infant Mortality in the United States.” American Journal of Public Health vol. 108,4 (2018): 565-567. Available at doi:10.2105/AJPH.2017.304218 (accessed August 27, 2021).

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