In a recently released issue of Pediatrics(10.1542/peds.2019-3178), Dr. Emily Johnston and colleagues at the Urban Institute’s Health Policy Center present an analysis of how the Affordable Care Act (ACA) Medicaid expansions influenced insurance coverage for new mothers living in poverty. Since Medicaid only covers maternal health needs through 60 days postpartum, the 2014 ACA-associated “expansion” of benefits to increase adult Medicaid eligibility to 138% of the Federal Poverty Level (FPL) in participating states (“expansion states”) made it possible for eligible new mothers to continue to have health insurance coverage beyond 60 days postpartum. In an accompanying commentary (10.1542/peds.2020-0401), Drs. Tina Cheng and Rachel Thornton emphasize to readers how critically helpful this change may be to new mothers and their families. However, not all states chose to participate in the expansion, and even among those that did, meaningful obstacles to enrollment for poor new mothers include lack of enrollment access, insufficient information about choices, and unhelpful local coverage provisions. Drs. Cheng and Thornton thus highlight the point that despite the opportunity offered by the expansion, thousands of new mothers remain uninsured.
In this fascinating study, new mothers were defined as women ages 19-44 years of age who gave birth in the past 12 months. The authors included only US citizens since non-citizens may not have access to Medicaid, and excluded women on SSI (Special Supplemental Income) or Medicare who may have other pathways to Medicaid coverage; the target population was women with incomes below 100% of the FPL since women with incomes 100-138% of the FPL may have access to marketplace subsidies in non-expansion states. They used the 2010-2017 American Community Survey as their data source, which included measures of maternal income, age, race/ethnicity, educational level, employment status, marital status, and geographic location. Nineteen of US states were non-expansion states. From 2013 to 2017, among non-expansion states, Medicaid eligibility thresholds for non-working parents as a percent of the FPL increased from a mean of 43% to 50%, while in expansion states, the change from 74% to 138% of FPL was larger, and clearly baseline eligibility was more generous. The meaning of this difference for numbers of uninsured mothers is dramatic, as the authors explain. They estimated the effect of Medicaid expansions on insurance coverage using a statistical approach that was able to reflect the (changing) Medicaid eligibility thresholds for parents in each state for each year. This was key since eligibility changed differently in different states. They also conducted sensitivity analyses to make sure that the many complexities and nuances of insurances did not unduly influence their findings: for example, they made separate models for women 19-25 years (who were eligible to remain on their parents’ insurance) and for women 26 years and older who were not. As a non-statistician I was relieved that I was able to work my way through this fairly complicated topic thanks to the authors’ clear explanations.
The authors found that the resulting proportions of women insured are dramatically different between non-expansion and expansion states: the average increase in Medicaid eligibility (the “expansion”) is associated with a 28% decrease in the rate of not having insurance, and a 13% increase in Medicaid coverage. Even more striking than the value of the expansion is the number of uninsured poor new mothers that fell between the cracks and did not have insurance in 2017, as emphasized by Drs. Cheng and Thornton in their commentary. All in, this number approaches 451,000. Understanding why women with access to insurance beyond 60 days postpartum are not enrolled is clearly another important avenue for research. Without ongoing maternal healthcare, huge opportunities are lost for treating maternal depression, providing contraception, supporting smoking cessation and treating maternal health issues such as hypertension. It is distressingly easy to understand why the US rate of pregnancy related deaths (defined as the death of a woman while pregnant or within 1 year of the end of a pregnancy) has increased significantly from 7.2 deaths per 100,000 live births (1987) to 16.7 deaths per 100,000 live births in 2016. This is a public health emergency and we have to do better: Dr. Johnston and colleagues have painstakingly documented one way forward through policy change. Both their article and the accompanying commentary have so much left to learn and explore – I hope you will dive in.
