BACKGROUND:

Medicaid plays a critical role during the perinatal period, but pregnancy-related Medicaid eligibility only extends for 60 days post partum. In 2014, the Affordable Care Act’s (ACA’s) Medicaid expansions increased adult Medicaid eligibility to 138% of the federal poverty level in participating states, allowing eligible new mothers to remain covered after pregnancy-related coverage expires. We investigate the impact of ACA Medicaid expansions on insurance coverage among new mothers living in poverty.

METHODS:

We define new mothers living in poverty as women ages 19 to 44 with incomes below the federal poverty level who report giving birth in the past 12 months. We use 2010–2017 American Community Survey data and a difference-in-differences approach using parental Medicaid-eligibility thresholds to estimate the effect of ACA Medicaid expansions on insurance coverage among poor new mothers.

RESULTS:

A 100-percentage-point increase in parental Medicaid-eligibility is associated with an 8.8-percentage-point decrease (P < .001) in uninsurance, a 13.2-percentage-point increase (P < .001) in Medicaid coverage, and a 4.4-percentage-point decrease in private or other coverage (P = .001) among poor new mothers. The average increase in Medicaid eligibility is associated with a 28% decrease in uninsurance, a 13% increase in Medicaid coverage, and an 18% decline in private or other insurance among poor new mothers in expansion states. However, in 2017, there were ∼142 000 remaining uninsured, poor new mothers.

CONCLUSIONS:

ACA Medicaid expansions are associated with increased Medicaid coverage and reduced uninsurance among poor new mothers. Opportunities remain for expansion and nonexpansion states to increase insurance coverage among new mothers living in poverty.

What’s Known on This Subject:

Affordable Care Act Medicaid expansions increased health insurance coverage and access to and affordability of care for adults, parents, and women of reproductive age. Parental insurance coverage has spillover benefits for children, including reduced uninsurance and improved family financial security.

What This Study Adds:

Affordable Care Act Medicaid expansions are associated with increased Medicaid coverage and reduced uninsurance among new mothers living in poverty. However, thousands of new mothers in the United States remained uninsured in 2017, and opportunities remain to increase coverage.

Medicaid plays a critical role during the perinatal period by covering prenatal care, delivery, and postpartum care for low-income women, including many not eligible for Medicaid coverage outside of pregnancy. By 1990, state Medicaid programs were federally mandated to provide pregnancy-related coverage to women with incomes up to 133% of the federal poverty level (FPL), and many states cover women with much higher incomes, with an average threshold of 200% of the FPL.1,2  In 2017, Medicaid paid for 43% of all births.3  However, pregnancy-related Medicaid eligibility only extends for 60 days post partum, and in 2005–2013, an estimated 55% of women with Medicaid coverage at delivery experienced uninsurance in their first 6 months post partum.4 

Insurance coverage for new mothers provides critical access to needed postpartum care, including care related to the delivery, behavioral and reproductive health services, and treatment of chronic conditions. Uninsurance after loss of pregnancy-related Medicaid coverage may also contribute to maternal mortality because 13.2% of maternal deaths occur >41 days post partum.5  Insurance coverage for parents has documented spillover benefits for children,6  including reduced uninsurance,712  increased receipt of recommended preventive care,1316  and improved family financial security.1719 

In 2014, the Affordable Care Act’s (ACA’s) Medicaid expansions increased adult Medicaid eligibility to 138% of the FPL in participating states (Table 1), allowing eligible new mothers to remain covered by Medicaid beyond 60 days post partum. Thus, we expect increases in coverage for poor new mothers in Medicaid-expansion states under the ACA. We also expect increased coverage for those in nonexpansion states because ACA outreach and enrollment efforts, the requirement to obtain health insurance or pay a penalty, and changes to income calculations used to assess eligibility all likely contributed to increases in enrollment among Medicaid-eligible adults in nonexpansion states.20  Moreover, new subsidies to purchase private insurance were available to individuals with incomes 100% to 138% of the FPL in nonexpansion states. Thus, assessing the impact of the Medicaid expansion itself on insurance coverage for new mothers living in poverty requires accounting for these other concurrent policy and program changes.

TABLE 1

Changes in Medicaid-Eligibility Thresholds for Nonworking Parents as a Percentage of the FPL, 2010–2017

Expansion States2013, %2017, %Percentage-Point ChangeNonexpansion States2013, %2017, %Percentage-Point Change
Alaska 74 138 64 Alabama 10 18 
Arizona 74 138 64 Florida 19 36 17 
Arkansas 13 138 125 Georgia 27 37 10 
California 100 138 38 Idaho 20 26 
Colorado 100 138 38 Kansas 25 38 13 
Connecticut 138 138 Maine 133 105 −28 
Delaware 100 138 38 Mississippi 23 27 
DC 138 138 Missouri 18 22 
Hawaii 100 138 38 Nebraska 47 63 16 
Illinois 133 138 North Carolina 34 44 10 
Indiana 18 138 120 Oklahoma 36 45 
Iowa 27 138 111 South Carolina 50 67 17 
Kentucky 33 138 105 South Dakota 50 50 
Louisiana 11 138 127 Tennessee 67 98 31 
Maryland 116 138 22 Texas 12 18 
Massachusetts 133 138 Utah 37 60 23 
Michigan 37 138 101 Virginia 25 38 13 
Minnesota 138 138 Wisconsin 138 105 −33 
Montana 31 138 107 Wyoming 37 55 18 
Nevada 24 138 114     
New Hampshire 38 138 100     
New Jersey 133 138     
New Mexico 28 138 110     
New York 138 138     
North Dakota 33 138 105     
Ohio 90 138 48     
Oregon 30 138 108     
Pennsylvania 25 138 113     
Rhode Island 138 138     
Vermont 138 138     
Washington 35 138 103     
West Virginia 16 138 122     
Mean 74 138 64 Mean 43 50 
Expansion States2013, %2017, %Percentage-Point ChangeNonexpansion States2013, %2017, %Percentage-Point Change
Alaska 74 138 64 Alabama 10 18 
Arizona 74 138 64 Florida 19 36 17 
Arkansas 13 138 125 Georgia 27 37 10 
California 100 138 38 Idaho 20 26 
Colorado 100 138 38 Kansas 25 38 13 
Connecticut 138 138 Maine 133 105 −28 
Delaware 100 138 38 Mississippi 23 27 
DC 138 138 Missouri 18 22 
Hawaii 100 138 38 Nebraska 47 63 16 
Illinois 133 138 North Carolina 34 44 10 
Indiana 18 138 120 Oklahoma 36 45 
Iowa 27 138 111 South Carolina 50 67 17 
Kentucky 33 138 105 South Dakota 50 50 
Louisiana 11 138 127 Tennessee 67 98 31 
Maryland 116 138 22 Texas 12 18 
Massachusetts 133 138 Utah 37 60 23 
Michigan 37 138 101 Virginia 25 38 13 
Minnesota 138 138 Wisconsin 138 105 −33 
Montana 31 138 107 Wyoming 37 55 18 
Nevada 24 138 114     
New Hampshire 38 138 100     
New Jersey 133 138     
New Mexico 28 138 110     
New York 138 138     
North Dakota 33 138 105     
Ohio 90 138 48     
Oregon 30 138 108     
Pennsylvania 25 138 113     
Rhode Island 138 138     
Vermont 138 138     
Washington 35 138 103     
West Virginia 16 138 122     
Mean 74 138 64 Mean 43 50 

The authors’ analysis of Kaiser Family Foundation data is shown. Numbers may not sum to the total because of rounding. States that expanded Medicaid under the ACA by January 2017 are classified as expansion states, and all others are classified as nonexpansion states. Thresholds are for nonworking parents in 2013 and for all parents in 2017. All thresholds are top coded at 138% of the FPL.

The positive effects of ACA Medicaid expansions on coverage, access, and affordability have been documented for adults,2130  parents,31  and women of reproductive age.32,33  Parental Medicaid-eligibility expansions in the pre-ACA period were found to increase coverage for women before pregnancy, but postpartum coverage was not examined.34  A recent descriptive analysis has revealed that uninsurance for all new mothers fell after the ACA.35,36  Here, we investigate the impact of ACA Medicaid expansions on coverage for poor new mothers to inform the potential coverage impacts for postpartum women if additional states were to expand Medicaid.

We use 2010–2017 American Community Survey (ACS) data from IPUMS.37  We incorporate edits to the insurance coverage measures to account for apparent misreporting and we generate income relative to the FPL for each woman’s health insurance unit (HIU) using an approach developed by the State Health Access Data Assistance Center.38,39  The Urban Institute Institutional Review Board determined that this analysis did not require institutional review board review because ACS data are publicly available and deidentified.

We define new mothers as women aged 19 to 44 years who report giving birth to any children born alive in the past 12 months. We limit our sample to include only US citizens because Medicaid eligibility is limited for noncitizens, and we exclude women who receive Supplemental Security Income (SSI) or Medicare because they have other pathways to Medicaid. We define the target population for the Medicaid expansion as women with HIU incomes <100% of the FPL. We exclude women with incomes 100% to 138% of the FPL because they may have access to Marketplace subsidies in nonexpansion states.

Health insurance coverage is self-reported at the time of the survey. When women report multiple types of coverage, we assign a single coverage type on the basis of the hierarchy: employer-sponsored insurance (ESI), Medicaid, private nongroup or Department of Veterans Affairs (VA) coverage, and uninsured. We focus on 3 categories of coverage: uninsurance, Medicaid, and private or other (VA, ESI, and nongroup coverage). We also use ACS measures of women’s sociodemographic characteristics, including income, age, race and/or ethnicity, educational attainment, employment, marital status, and metropolitan status (Table 2). Finally, we draw annual state unemployment rates from the IPUMS Current Population Survey database.40 

TABLE 2

Characteristics of New Mothers Living in Poverty by State Medicaid-Expansion Status, 2013 and 2017

20132017
New Mothers Living in PovertyNew Mothers Living in Poverty
All StatesExpansion StatesNonexpansion StatesAll StatesExpansion StatesNonexpansion States
Medicaid-expansion status, %       
 Expansion state 57.9 100.0 0.0 56.5 100.0 0.0 
 Nonexpansion state 42.1 0.0 100.0 43.5 0.0 100.0 
Income, %       
 <50% of the FPL 66.5 66.8 66.1 63.8** 62.2*** 65.9^ 
 50%–100% of the FPL 33.5 33.2 33.9 36.2** 37.8*** 34.1^ 
Insurance coverage, %       
 Uninsured 25.9 18.9 35.7^^^ 15.2*** 7.8*** 24.8*** ^^^ 
 Medicaid 56.1 63.7 45.7^^^ 65.0*** 75.4*** 51.6*** ^^^ 
 Private or other 17.9 17.4 18.6 19.8* 16.8 23.6*** ^^^ 
  ESI 16.9 16.5 17.5 17.9 15.7 20.8** ^^^ 
  Nongroup 1.0 0.9 1.1 1.7*** 1.0 2.6*** ^^^ 
  VA 0.07 0.04 0.1 0.1 0.1 0.2 
Age, y, %       
 19–25 57.0 55.4 59.3^^ 48.2*** 46.5*** 50.4*** ^^ 
 26–34 34.6 36.0 32.7^ 40.6*** 42.3*** 38.5*** ^ 
 35–44 8.4 8.6 8.0 11.1*** 11.2*** 11.0** 
Race and/or ethnicity, %       
 White, non-Hispanic 47.2 47.6 46.6 43.7*** 44.5* 42.6** 
 African American, non-Hispanic 24.8 20.3 31.0^^^ 25.4 20.4 31.9^^^ 
 Hispanic 21.5 24.4 17.6^^^ 23.7* 26.0 20.6* ^^^ 
 Other, non-Hispanic 6.4 7.7 4.7^^^ 7.3 9.0* 4.9^^^ 
Educational attainment, %       
 Less than HS 19.6 20.0 19.0 17.9* 18.8 16.8 
 HS graduate 36.2 36.0 36.4 38.2* 38.3 38.2 
 Some college 38.5 38.2 39.0 37.2 36.2 38.4 
 College graduate 5.7 5.8 5.6 6.7* 6.7 6.6 
Employment status, %       
 Employed 37.0 36.5 37.7 39.4* 40.2** 38.2 
 Unemployed 16.8 15.6 18.6^^ 11.5*** 11.2*** 11.9*** 
 Not in labor force 46.2 47.9 43.8^^ 49.2** 48.6 49.8*** 
Marital status, %       
 Married 25.7 25.3 26.3 23.2** 24.0 22.1** 
Metropolitan status, %       
 Metropolitan 73.2 77.2 67.7^^^ 73.4 77.1 68.6^^^ 
 Nonmetropolitan 10.7 9.6 12.2^^ 10.9 10.2 11.7 
 Not identifiable 16.1 13.2 20.2^^^ 15.7 12.7 19.7^^^ 
State unemployment rate, % 7.4 7.8 6.9^^^ 4.4*** 4.6*** 4.2*** ^^^ 
Unweighted, n 8966 5233 3733 7672 4468 3204 
20132017
New Mothers Living in PovertyNew Mothers Living in Poverty
All StatesExpansion StatesNonexpansion StatesAll StatesExpansion StatesNonexpansion States
Medicaid-expansion status, %       
 Expansion state 57.9 100.0 0.0 56.5 100.0 0.0 
 Nonexpansion state 42.1 0.0 100.0 43.5 0.0 100.0 
Income, %       
 <50% of the FPL 66.5 66.8 66.1 63.8** 62.2*** 65.9^ 
 50%–100% of the FPL 33.5 33.2 33.9 36.2** 37.8*** 34.1^ 
Insurance coverage, %       
 Uninsured 25.9 18.9 35.7^^^ 15.2*** 7.8*** 24.8*** ^^^ 
 Medicaid 56.1 63.7 45.7^^^ 65.0*** 75.4*** 51.6*** ^^^ 
 Private or other 17.9 17.4 18.6 19.8* 16.8 23.6*** ^^^ 
  ESI 16.9 16.5 17.5 17.9 15.7 20.8** ^^^ 
  Nongroup 1.0 0.9 1.1 1.7*** 1.0 2.6*** ^^^ 
  VA 0.07 0.04 0.1 0.1 0.1 0.2 
Age, y, %       
 19–25 57.0 55.4 59.3^^ 48.2*** 46.5*** 50.4*** ^^ 
 26–34 34.6 36.0 32.7^ 40.6*** 42.3*** 38.5*** ^ 
 35–44 8.4 8.6 8.0 11.1*** 11.2*** 11.0** 
Race and/or ethnicity, %       
 White, non-Hispanic 47.2 47.6 46.6 43.7*** 44.5* 42.6** 
 African American, non-Hispanic 24.8 20.3 31.0^^^ 25.4 20.4 31.9^^^ 
 Hispanic 21.5 24.4 17.6^^^ 23.7* 26.0 20.6* ^^^ 
 Other, non-Hispanic 6.4 7.7 4.7^^^ 7.3 9.0* 4.9^^^ 
Educational attainment, %       
 Less than HS 19.6 20.0 19.0 17.9* 18.8 16.8 
 HS graduate 36.2 36.0 36.4 38.2* 38.3 38.2 
 Some college 38.5 38.2 39.0 37.2 36.2 38.4 
 College graduate 5.7 5.8 5.6 6.7* 6.7 6.6 
Employment status, %       
 Employed 37.0 36.5 37.7 39.4* 40.2** 38.2 
 Unemployed 16.8 15.6 18.6^^ 11.5*** 11.2*** 11.9*** 
 Not in labor force 46.2 47.9 43.8^^ 49.2** 48.6 49.8*** 
Marital status, %       
 Married 25.7 25.3 26.3 23.2** 24.0 22.1** 
Metropolitan status, %       
 Metropolitan 73.2 77.2 67.7^^^ 73.4 77.1 68.6^^^ 
 Nonmetropolitan 10.7 9.6 12.2^^ 10.9 10.2 11.7 
 Not identifiable 16.1 13.2 20.2^^^ 15.7 12.7 19.7^^^ 
State unemployment rate, % 7.4 7.8 6.9^^^ 4.4*** 4.6*** 4.2*** ^^^ 
Unweighted, n 8966 5233 3733 7672 4468 3204 

The authors’ analysis of data from the 2013 and 2017 ACS and Current Population Survey is shown. Numbers may not sum to the total because of rounding. States that expanded Medicaid under the ACA by January 2017 are classified as expansion states, and all others are classified as nonexpansion states. Not identifiable metropolitan status indicates that the respondent’s sampling area straddled a metropolitan area boundary, and therefore metropolitan area status could not be reliably identified. The sample is limited to women ages 19 to 44 y who are US citizens, did not report Medicare coverage, did not report receiving SSI, and reported having given birth to any children in the past 12 mo. HS, high school.

*

P < .05; ** P < .01; *** P < .001 for the difference between 2013 and 2017.

^

P < .05; ^^ P < .01; ^^^ P < .001 for the within-year difference between expansion and nonexpansion states.

We use a binary measure of Medicaid-expansion status that classifies states that expanded Medicaid under the ACA by January 2017 as expansion states and all others as nonexpansion states. We also use a continuous measure of Medicaid eligibility that captures the income eligibility thresholds for each year from 2010 to 2017, drawn from Kaiser Family Foundation reports.2,41  Specifically, we use the eligibility thresholds for nonworking parents in 2010–2013 and for all parents in 2014–2017. Eligibility is no longer differentiated by work status after changes under the ACA.42 

We first describe patterns of insurance coverage among new mothers living in poverty by year and expansion status and estimate unadjusted differences. We then estimate the effect of Medicaid expansions on insurance coverage using a difference-in-differences approach with a continuous policy variable that reflects the Medicaid-eligibility threshold for parents in a given state and year. By including each year’s threshold, we capture both the presence and the magnitude of eligibility expansions across states over time. This is important because there was considerable variation in the pre-ACA Medicaid-eligibility thresholds for parents (Table 1).

We estimate linear probability models for ease of interpretation and top-code eligibility thresholds at 138% of the FPL to avoid capturing changes in eligibility for higher-income populations that do not affect the women in our sample. All models control for women’s sociodemographic characteristics, state unemployment rate, state fixed effects, and year fixed effects. SEs are clustered at the state level, and models use survey weights.

For simplicity, we report the estimated effect of a 100-percentage-point increase in the Medicaid income eligibility threshold for parents. Estimates can be scaled to inform the expected effects of expansions of other sizes (eg, 50-percentage-points) because the model assumes a linear relationship between eligibility and our outcomes of interest.

Because Medicaid expansions may have disproportionately affected different groups of poor new mothers, we also stratify our sample by race and/or ethnicity (non-Hispanic white, non-Hispanic African American, Hispanic, and other race or multiple races) and income (<50% of the FPL and 50% to <100% of the FPL).

We consider alternate definitions of new mothers living in poverty: new mothers with incomes <138% of the FPL and women with incomes <100% of the FPL who report giving birth in the past 12 months and have a child aged <1 in their household. This second sample is smaller because the ACS undercounts young children in the United States.43  Next, we consider alternate measures of Medicaid-eligibility thresholds: a nonworking parental Medicaid threshold not capped at 138% of the FPL and a capped Medicaid threshold for working parents. We also consider an unweighted model, a model with state-specific linear time trends, and a model using a Medicaid-topped insurance hierarchy. Because evidence suggests that the ACA dependent coverage mandate increased coverage for young women with a recent birth,44  we estimate separate models for young adult women eligible to remain on their parent’s insurance (ages 19–25) and for women not eligible for this provision (ages 26–44). We also test the sensitivity of our estimates to the inclusion of noncitizen women because some are eligible for Medicaid depending on their legal status, time in the United States, and state of residence. Finally, we test the sensitivity of our results to policy-relevant state and year exclusions.

Before ACA Medicaid expansion, poor new mothers in nonexpansion states were nearly twice as likely to be uninsured as those in expansion states (35.7% compared with 18.9%; P < .001; Fig 1). After implementation of the major coverage provisions of the ACA, the uninsurance rate for poor new mothers fell 41%, from 25.9% in 2013 to 15.2% in 2017 (P < .001). The percentage-point decrease in uninsurance was similar in expansion and nonexpansion states, but the increase in Medicaid coverage was larger in expansion states (63.7% to 75.4%; P < .001) than in nonexpansion states (45.7% to 51.6%; P < .001). Although private or other coverage increased in nonexpansion states, we do not observe a significant change in expansion states. By 2017, the uninsurance rate for poor new mothers in nonexpansion states was 3.2 times higher than in expansion states, and the Medicaid coverage rate was 1.5 times higher in expansion states than in nonexpansion states. As shown in Table 2, the characteristics of poor new mothers living in poverty change over our study period and vary between those living in expansion and nonexpansion states, highlighting the importance of controlling for these characteristics in our impact analysis.

FIGURE 1

Insurance coverage among new mothers living in poverty in 2013 and 2017. The authors’ analysis of data from the 2013 and 2017 ACS is shown. Within-group differences between 2013 and 2017 are significantly different at the P < .001 level for all coverage types except for private or other coverage in all states, which is significantly different between years at the P < .01 level, and private or other coverage in expansion states, which is not significantly different between years. Within-year differences between expansion and nonexpansion states are significantly different at the P < .001 level for all coverage types except for private or other coverage in 2013, which is not significantly different. States that expanded Medicaid under the ACA by January 2017 are classified as expansion states, and all others are classified as nonexpansion states. Private or other coverage includes ESI, nongroup coverage, and coverage through the VA. The sample is limited to women ages 19 to 44 years who are US citizens, did not report Medicare coverage, did not report receiving SSI, have household incomes <100% of the FPL, and reported having given birth to any children in the past 12 months. See Table 2 for sample sizes.

FIGURE 1

Insurance coverage among new mothers living in poverty in 2013 and 2017. The authors’ analysis of data from the 2013 and 2017 ACS is shown. Within-group differences between 2013 and 2017 are significantly different at the P < .001 level for all coverage types except for private or other coverage in all states, which is significantly different between years at the P < .01 level, and private or other coverage in expansion states, which is not significantly different between years. Within-year differences between expansion and nonexpansion states are significantly different at the P < .001 level for all coverage types except for private or other coverage in 2013, which is not significantly different. States that expanded Medicaid under the ACA by January 2017 are classified as expansion states, and all others are classified as nonexpansion states. Private or other coverage includes ESI, nongroup coverage, and coverage through the VA. The sample is limited to women ages 19 to 44 years who are US citizens, did not report Medicare coverage, did not report receiving SSI, have household incomes <100% of the FPL, and reported having given birth to any children in the past 12 months. See Table 2 for sample sizes.

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After accounting for observed characteristics of new mothers, state fixed effects, and secular trends, we find that a 100-percentage-point increase in the parental Medicaid-eligibility threshold is associated with an 8.8-percentage-point decrease (P < .001; Table 3) in uninsurance among poor new mothers. The same increase in eligibility is associated with a 13.2-percentage-point increase (P < .001) in Medicaid coverage among poor new mothers. We also find a negative association between Medicaid eligibility and private or other coverage (4.4 percentage points; P = .001), suggesting that approximately one-third of the gain in Medicaid coverage reflects substitution of other coverage sources. These findings suggest that the average increase in Medicaid eligibility across expansion states of 64 percentage points is associated with a 5.6-percentage-point decrease in uninsurance, a 28% decrease from the pre-ACA mean in expansion states. The same average increase is associated with an 8.5-percentage-point increase in Medicaid coverage and a 2.8-percentage-point decline in private or other coverage among poor new mothers, all else equal.

TABLE 3

Effects of Parental Medicaid Expansions on Insurance Coverage Among New Mothers Living in Poverty, 2010–2017

 2010–2013 Expansion State Mean Estimate SE P 
New mothers with incomes <100% of the FPL (n = 69 060)     
 Uninsured 0.198 −0.088 0.019 .000 
 Medicaid 0.646 0.132 0.024 .000 
 Private or other 0.155 −0.044 0.013 .001 
 2010–2013 Expansion State Mean Estimate SE P 
New mothers with incomes <100% of the FPL (n = 69 060)     
 Uninsured 0.198 −0.088 0.019 .000 
 Medicaid 0.646 0.132 0.024 .000 
 Private or other 0.155 −0.044 0.013 .001 

The authors’ analysis of data from the 2010–2017 ACS is shown. Estimates reflect the effect of a 100-percentage-point change in the state Medicaid-eligibility threshold for parents on the outcome of interest. States that expanded Medicaid under the ACA by January 2017 are classified as expansion states, and all others are classified as nonexpansion states. Private or other coverage includes ESI, nongroup coverage, and coverage through the VA. The sample is limited to women ages 19 to 44 y who are US citizens, did not report Medicare coverage, did not report receiving SSI, have household incomes <100% of the FPL, and reported having given birth to any children in the past 12 mo.

When stratified by race and/or ethnicity (Table 4), we find that a 100-percetage point increase in Medicaid eligibility is associated with a 10-percentage-point reduction in uninsurance among Hispanic and white new mothers (P = .002 and P < .001), a 7-percentage-point reduction for new mothers of other or multiple races (P = .02), and a nearly 5-percentage-point reduction for African American new mothers (P = .09). Eligibility increases were associated with gains in Medicaid coverage for all groups. Coverage gains in the other race or multiple races category appear to be driven by gains for American Indian and Alaskan native new mothers (Supplemental Table 6).

TABLE 4

Effects of Parental Medicaid Expansions on Insurance Coverage Among New Mothers Living in Poverty, 2010–2017, by Race and/or Ethnicity

2010–2013 Expansion State MeanEstimateSEP
White women (n = 34 999)     
 Uninsured 0.214 −0.100 0.023 .000 
 Medicaid 0.609 0.144 0.033 .000 
 Private or other 0.177 −0.045 0.018 .016 
African American women (n = 14 457)     
 Uninsured 0.156 −0.046 0.026 .087 
 Medicaid 0.718 0.093 0.031 .005 
 Private or other 0.126 −0.047 0.017 .009 
Hispanic women (n = 14 044)     
 Uninsured 0.203 −0.102 0.031 .002 
 Medicaid 0.657 0.155 0.043 .001 
 Private or other 0.140 −0.052 0.028 .066 
Women of another race or multiple races (n = 5560)     
 Uninsured 0.207 −0.071 0.028 .016 
 Medicaid 0.644 0.073 0.038 .056 
 Private or other 0.149 −0.003 0.024 .912 
2010–2013 Expansion State MeanEstimateSEP
White women (n = 34 999)     
 Uninsured 0.214 −0.100 0.023 .000 
 Medicaid 0.609 0.144 0.033 .000 
 Private or other 0.177 −0.045 0.018 .016 
African American women (n = 14 457)     
 Uninsured 0.156 −0.046 0.026 .087 
 Medicaid 0.718 0.093 0.031 .005 
 Private or other 0.126 −0.047 0.017 .009 
Hispanic women (n = 14 044)     
 Uninsured 0.203 −0.102 0.031 .002 
 Medicaid 0.657 0.155 0.043 .001 
 Private or other 0.140 −0.052 0.028 .066 
Women of another race or multiple races (n = 5560)     
 Uninsured 0.207 −0.071 0.028 .016 
 Medicaid 0.644 0.073 0.038 .056 
 Private or other 0.149 −0.003 0.024 .912 

The authors’ analysis of data from the 2010–2017 ACS is shown. Estimates reflect the effect of a 100-percentage-point change in the state Medicaid-eligibility threshold for parents on the outcome of interest. The pre-ACA mean is among expansion states in the years 2010–2013. States that expanded Medicaid under the ACA by January 2017 are classified as expansion states, and all others are classified as nonexpansion states. African American and white samples are limited to non-Hispanic women reporting only one race. Private or other coverage includes ESI, nongroup coverage, and coverage through the VA. The sample is limited to women ages 19 to 44 y who are US citizens, did not report Medicare coverage, did not report receiving SSI, have household incomes <100% of the FPL, and reported having given birth to any children in the past 12 mo.

When stratified by income (Table 5), a 100-percentage-point increase in eligibility is associated with a 9.0-percentage-point increase in coverage (P < .001) for both groups. For new mothers with incomes <50% of the FPL, expansion is associated with an 11.6-percentage-point increase in Medicaid coverage (P < .001), compared with a 16.7-percentage-point increase for new mothers with incomes 50% to <100% of the FPL (P < .001).

TABLE 5

Effects of Parental Medicaid Expansions on Insurance Coverage Among New Mothers Living in Poverty, 2010–2017, by Income

Income <50% of the FPL (n = 44 706)Income 50%–<100% of the FPL (n = 24 354)
2010–2013 Expansion State MeanEstimateSEP2010–2013 Expansion State MeanEstimateSEP
Uninsured 0.192 −0.090 0.021 .000 0.210 −0.088 0.020 .000 
Medicaid 0.669 0.116 0.026 .000 0.602 0.167 0.025 .000 
Private or other 0.139 −0.026 0.014 .069 0.187 −0.079 0.020 .000 
Income <50% of the FPL (n = 44 706)Income 50%–<100% of the FPL (n = 24 354)
2010–2013 Expansion State MeanEstimateSEP2010–2013 Expansion State MeanEstimateSEP
Uninsured 0.192 −0.090 0.021 .000 0.210 −0.088 0.020 .000 
Medicaid 0.669 0.116 0.026 .000 0.602 0.167 0.025 .000 
Private or other 0.139 −0.026 0.014 .069 0.187 −0.079 0.020 .000 

The authors’ analysis of data from the 2010–2017 ACS is shown. Estimates reflect the effect of a 100-percentage-point change in the state Medicaid-eligibility threshold for parents on the outcome of interest. States that expanded Medicaid under the ACA by January 2017 are classified as expansion states, and all others are classified as nonexpansion states. Private or other coverage includes ESI, nongroup coverage, and coverage through the VA. The sample is limited to women ages 19 to 44 y who are US citizens, did not report Medicare coverage, did not report receiving SSI, have household incomes <100% of the FPL, and reported having given birth to any children in the past 12 mo.

Our results are robust to alternate definitions of new mothers (Supplemental Table 7), alternate eligibility thresholds (Supplemental Table 8), and alternate model specifications (Supplemental Table 9), varying modestly in magnitude but maintaining the same direction and general patterns. Effects appear stronger for women not affected by the dependent coverage provision than for the full sample or young adult women (Supplemental Table 10). Including noncitizen women produces slightly weaker estimates than our main model. We find no statistically significant effects for the small sample of noncitizen women; estimates are consistent in direction with those for citizen women but are smaller in magnitude (Supplemental Table 11). Results are somewhat stronger when we omit 2014 or late Medicaid-expansion states (Supplemental Table 12).

Our model suggests that if the nonexpansion states had expanded, the uninsurance rate among our sample of new mothers in these states would have fallen to 17.6% in 2017 (Fig 2), suggesting that ∼29 000 poor new mothers in nonexpansion states could have gained coverage. In 2017, there were ∼451 000 uninsured new mothers overall, 31% of whom were citizen women with incomes below the poverty level (the target population for the ACA Medicaid expansion) (Fig 3). Of these ∼142 000 uninsured citizen new mothers living in poverty, 29% lived in expansion states and the other 71% lived in nonexpansion states. An additional 161 000 noncitizen new mothers were uninsured in 2017, some of whom may be eligible for Medicaid coverage, along with ∼146 000 new mothers with incomes above the FPL, including 21 000 with incomes 100% to 138% of the FPL in nonexpansion states.

FIGURE 2

Type of insurance coverage among new mothers living in poverty in nonexpansion states in 2017, both actual and predicted if states had expanded eligibility for Medicaid. The authors’ analysis of data from the 2010–2017 ACS is shown. States that expanded Medicaid under the ACA by January 2017 are classified as expansion states, and all others are classified as nonexpansion states. Private or other coverage includes ESI, nongroup coverage, and coverage through the VA. The sample is limited to women ages 19 to 44 years who are US citizens, did not report Medicare coverage, did not report receiving SSI, have household incomes <100% of the FPL, and reported having given birth to any children in the past 12 months. ** P < .01; *** P < .001.

FIGURE 2

Type of insurance coverage among new mothers living in poverty in nonexpansion states in 2017, both actual and predicted if states had expanded eligibility for Medicaid. The authors’ analysis of data from the 2010–2017 ACS is shown. States that expanded Medicaid under the ACA by January 2017 are classified as expansion states, and all others are classified as nonexpansion states. Private or other coverage includes ESI, nongroup coverage, and coverage through the VA. The sample is limited to women ages 19 to 44 years who are US citizens, did not report Medicare coverage, did not report receiving SSI, have household incomes <100% of the FPL, and reported having given birth to any children in the past 12 months. ** P < .01; *** P < .001.

Close modal
FIGURE 3

Characteristics of the remaining uninsured new mothers in 2017. The authors’ analysis of data from the 2017 ACS is shown. Categories may not sum to the total because of rounding, and the figure does not include an additional 1000 uninsured new mothers receiving SSI. States that expanded Medicaid under the ACA by January 2017 are classified as expansion states, and all others are classified as nonexpansion states. All categories, except for uninsured noncitizen new mothers, are limited to citizen women, and all categories, except uninsured new mothers receiving SSI, are limited to women not receiving SSI. The sample is limited to women ages 19 to 44 years who reported having given birth to any children in the past 12 months and are uninsured.

FIGURE 3

Characteristics of the remaining uninsured new mothers in 2017. The authors’ analysis of data from the 2017 ACS is shown. Categories may not sum to the total because of rounding, and the figure does not include an additional 1000 uninsured new mothers receiving SSI. States that expanded Medicaid under the ACA by January 2017 are classified as expansion states, and all others are classified as nonexpansion states. All categories, except for uninsured noncitizen new mothers, are limited to citizen women, and all categories, except uninsured new mothers receiving SSI, are limited to women not receiving SSI. The sample is limited to women ages 19 to 44 years who reported having given birth to any children in the past 12 months and are uninsured.

Close modal

Consistent with the growing literature on the effects of ACA Medicaid expansions on insurance coverage, we find that ACA Medicaid expansions are associated with decreased uninsurance and increased Medicaid coverage for an important population: new mothers living in poverty. Our findings suggest that the average increase in the Medicaid-eligibility threshold under the ACA is associated with a 28% decrease in uninsurance, a 13% increase in Medicaid coverage, and an 18% decline in private or other insurance among poor new mothers in expansion states.

The effects of the average increase in Medicaid eligibility on uninsurance in our sample of poor new mothers were pronounced for Hispanic and white women, with Hispanic women experiencing a 32% decline and white women a 30% decline, in contrast to a 19% decline for African American new mothers. This difference may be due, in part, to differences in preexpansion coverage by race and/or ethnicity. In expansion states in 2010–2013, African American new mothers were less likely to be uninsured than white or Hispanic new mothers and more likely to be covered by Medicaid. The racial and ethnic distribution of new mothers in expansion versus nonexpansion states may also contribute to this pattern because African American women disproportionately reside in nonexpansion states.45,46 

The average increase in Medicaid eligibility is associated with an 18% increase in Medicaid coverage for new mothers with incomes 50% to <100% of the FPL, compared with an 11% increase for women with the lowest incomes. Again, this may be due to differences in preexpansion coverage because new mothers residing in expansion states in 2010–2013 with incomes <50% of the FPL were more likely to be eligible for and enrolled in Medicaid than those with higher incomes.

Although we find that the Medicaid expansions are associated with increased Medicaid coverage and reduced uninsurance, we also find reductions in private or other coverage. We do not actually observe reductions in private or other coverage among poor new mothers in Medicaid-expansion states. Rather, new mothers living in poverty in nonexpansion states were more likely to be covered by private or other insurance in 2017 compared with 2013, whereas we observe no change among new mothers in expansion states. Some of this may reflect the availability of subsidized Marketplace coverage at lower income levels in nonexpansion states.

In this analysis, we cannot assess the quality of the available private coverage. Private or other insurance is generally more costly than Medicaid, given typical cost-sharing and benefit structures, but may offer a broader choice of providers.47  Maintaining Medicaid coverage in the postpartum period for women already covered by pregnancy-related Medicaid may reduce disruptions in a woman’s usual source of care.4,36,48  Thus, there are important trade-offs between Medicaid and private coverage to consider when evaluating the importance of shifting between private and public coverage.

As policy makers at the state and federal levels consider legislation to extend pregnancy-related Medicaid coverage from 60 days to 1 year post partum,35  the results of this study suggest that such policies would reduce uninsurance for women at a time when they and their families have important health care needs. In 2017, we estimate that >122 000 new mothers with incomes <138% of the FPL were uninsured and residing in nonexpansion states. These women could gain coverage if their state implemented ACA Medicaid expansion or expanded pregnancy-related Medicaid eligibility post partum. In addition, we estimate that ∼51 000 citizen new mothers with incomes <138% of the FPL were uninsured and residing in Medicaid-expansion states. These women are likely eligible for Medicaid and could benefit from investments to increase take-up of Medicaid coverage, such as outreach, education, and policies that support continuous eligibility as women transition from pregnancy-related Medicaid eligibility to eligibility as low-income adults. Additional policy efforts would likely be required to reduce uninsurance among the other nearly 277 000 uninsured new mothers, including those with higher incomes and noncitizens.

This study has important limitations. Identification of new mothers is based on ACS respondents’ answer to the question of whether a woman in their household gave birth to a living child in the past 12 months. To address concerns about measurement error, we conduct a sensitivity analysis limiting the sample to women with a birth in the past 12 months with a child <1 year of age in their household and find similar results. However, this alternative sample is likely an undercount of new mothers, given the well-documented problem of young children being undercounted in the ACS.43  Because we do not know when in the past 12 months a woman gave birth, some women in our sample may still be within 60 days post partum and may still be eligible for pregnancy-related Medicaid, resulting in an underestimate of uninsurance for new mothers outside of the 60-day window. Our measures of insurance coverage are self-reported and subject to recall and social desirability biases. Although we incorporate edits to the insurance coverage measures to account for apparent misreporting, measurement error likely remains.38  Finally, there is an additional measurement error in the measure of HIU income relative to poverty that we use to define our sample. There are likely reporting errors as well as family units that do not line up precisely with Medicaid-eligibility rules. Furthermore, the income measure reflects annual income, and Medicaid eligibility is determined by monthly income.49  Finally, this analysis highlights important areas for future research, such as the relationship between state Medicaid eligibility for noncitizen women and coverage among noncitizen new mothers, and the effects of ACA Medicaid expansion on new mothers’ employment status.

Approximately 451 000 new mothers were uninsured in 2017, ∼142 000 of whom were citizen women living in poverty. Nonexpansion states could reduce uninsurance among poor new mothers by expanding Medicaid. Alternatively, they could seek waivers to extend pregnancy-related Medicaid eligibility for >60 days post partum, which could help more new mothers attend to their health needs but would not address coverage gaps among new fathers or poor parents outside of the postpartum period. Expansion states could increase coverage through education, outreach, and enrollment efforts such as waivers providing 12-month continuous Medicaid eligibility to parents. Ensuring that new mothers living in poverty have insurance coverage has the potential to help women access and afford necessary physical and mental health care, reduce stress and financial hardship, and improve the health and well-being of their entire family.

Dr Johnston conceptualized and designed the study, conducted the data analysis, drafted the initial manuscript, and reviewed and revised the manuscript; Dr McMorrow conceptualized and designed the study, reviewed the data analysis, and reviewed and revised the manuscript; Mr Thomas conducted the data analysis and reviewed and revised the manuscript; Dr Kenney conceptualized and designed the study and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: Funded by the David and Lucile Packard Foundation.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/0.1542/peds.2020-0401.

     
  • ACA

    Affordable Care Act

  •  
  • ACS

    American Community Survey

  •  
  • ESI

    employer-sponsored insurance

  •  
  • FPL

    federal poverty level

  •  
  • HIU

    health insurance unit

  •  
  • SSI

    Supplemental Security Income

  •  
  • VA

    Department of Veterans Affairs

1
Ellwood
MR
,
Kenney
G
.
Medicaid and pregnant women: who is being enrolled and when
.
Health Care Financ Rev
.
1995
;
17
(
2
):
7
28
2
Henry
J.
Kaiser Family Foundation.
Medicaid and CHIP income eligibility limits for pregnant women, 2003–2019.
2019
. Available at: https://www.kff.org/medicaid/state-indicator/medicaid-and-chip-income-eligibility-limits-for-pregnant-women/. Accessed August 9, 2019
3
Martin
JA
,
Hamilton
BE
,
Osterman
MJK
.
Births in the United States, 2017
.
Hyattsville, MD
:
National Center for Health Statistics
;
2018
. Available at: https://www.cdc.gov/nchs/products/databriefs/db318.htm. Accessed August 9, 2019
4
Daw
JR
,
Hatfield
LA
,
Swartz
K
,
Sommers
BD
.
Women in the United States experience high rates of coverage ‘churn’ in months before and after childbirth
.
Health Aff (Millwood)
.
2017
;
36
(
4
):
598
606
5
Creanga
AA
,
Syverson
C
,
Seed
K
,
Callaghan
WM
.
Pregnancy-related mortality in the United States, 2011–2013
.
Obstet Gynecol
.
2017
;
130
(
2
):
366
373
6
Burak
EW
.
Health Coverage for Parents and Caregivers Helps Children
.
Washington, DC
:
Georgetown University Health Policy Institute Center for Children and Families
;
2017
7
Smith
AJB
,
Chien
AT
.
Adult-oriented health reform and children’s insurance and access to care: evidence from Massachusetts health reform
.
Matern Child Health J
.
2019
;
23
(
8
):
1008
1024
8
Hamersma
S
,
Kim
M
,
Timpe
B
.
The effect of parental Medicaid expansions on children’s health insurance coverage
.
Contemp Econ Policy
.
2019
;
37
(
2
):
297
311
9
Dubay
L
,
Kenney
G
.
Expanding public health insurance to parents: effects on children’s coverage under Medicaid
.
Health Serv Res
.
2003
;
38
(
5
):
1283
1301
10
DeVoe
JE
,
Marino
M
,
Angier
H
, et al
.
Effect of expanding medicaid for parents on children’s health insurance coverage: lessons from the Oregon experiment
.
JAMA Pediatr
.
2015
;
169
(
1
):
e143145
11
Hudson
JL
,
Moriya
AS
.
Medicaid expansion for adults had measurable ‘welcome mat’ effects on their children
.
Health Aff (Millwood)
.
2017
;
36
(
9
):
1643
1651
12
Aizer
A
,
Grogger
J
.
Parental Medicaid expansions and health insurance coverage
.
2003
. Available at: www.nber.org/papers/w9907. Accessed July 29, 2015
13
Venkataramani
M
,
Pollack
CE
,
Roberts
ET
.
Spillover effects of adult Medicaid expansions on children’s use of preventive services
.
Pediatrics
.
2017
;
140
(
6
):
e20170953
14
Davidoff
A
,
Dubay
L
,
Kenney
G
,
Yemane
A
.
The effect of parents’ insurance coverage on access to care for low-income children
.
Inquiry
.
2003
;
40
(
3
):
254
268
15
Gifford
EJ
,
Weech-Maldonado
R
,
Short
PF
.
Low-income children’s preventive services use: implications of parents’ Medicaid status
.
Health Care Financ Rev
.
2005
;
26
(
4
):
81
94
16
Guendelman
S
,
Wier
M
,
Angulo
V
,
Oman
D
.
The effects of child-only insurance coverage and family coverage on health care access and use: recent findings among low-income children in California
.
Health Serv Res
.
2006
;
41
(
1
):
125
147
17
Hu
L
,
Kaestner
R
,
Mazumder
B
,
Miller
S
,
Wong
A
.
The effect of the Affordable Care Act Medicaid expansions on financial wellbeing
.
J Public Econ
.
2018
;
163
:
99
112
18
Caswell
KJ
,
Waidmann
TA
.
The Affordable Care Act Medicaid expansions and personal finance
.
Med Care Res Rev
.
2019
;
76
(
5
):
538
571
19
Wherry
LR
,
Kenney
GM
,
Sommers
BD
.
The role of public health insurance in reducing child poverty
.
Acad Pediatr
.
2016
;
16
(
suppl 3
):
S98
S104
20
Kenney
GM
,
Haley
J
,
Pan
C
,
Lynch
V
,
Buettgens
M
.
A Look at Early ACA Implementation: State and National Medicaid Patterns for Adults in 2014
.
Washington, DC
:
Urban Institute
;
2016
21
Simon
K
,
Soni
A
,
Cawley
J
.
The impact of health insurance on preventive care and health behaviors: evidence from the first two years of the ACA Medicaid expansions
.
J Policy Anal Manage
.
2017
;
36
(
2
):
390
417
22
Courtemanche
C
,
Marton
J
,
Ukert
B
,
Yelowitz
A
,
Zapata
D
.
Early impacts of the Affordable Care Act on health insurance coverage in Medicaid expansion and non-expansion states
.
J Policy Anal Manage
.
2017
;
36
(
1
):
178
210
23
Miller
S
,
Wherry
LR
.
Four years later: insurance coverage and access to care continue to diverge between ACA Medicaid expansion and non-expansion states
.
AEA Pap Proc
.
2019
;
109
:
327
333
24
Miller
S
,
Wherry
LR
.
Health and access to care during the first 2 years of the ACA Medicaid expansions
.
N Engl J Med
.
2017
;
376
(
10
):
947
956
25
Wherry
LR
,
Miller
S
.
Early coverage, access, utilization, and health effects associated with the Affordable Care Act Medicaid expansions: a quasi-experimental study
.
Ann Intern Med
.
2016
;
164
(
12
):
795
803
26
Kaestner
R
,
Garrett
B
,
Chen
J
,
Gangopadhyaya
A
,
Fleming
C
.
Effects of ACA Medicaid expansions on health insurance coverage and labor supply
.
J Policy Anal Manage
.
2017
;
36
(
3
):
608
642
27
Sommers
BD
,
Gunja
MZ
,
Finegold
K
,
Musco
T
.
Changes in self-reported insurance coverage, access to care, and health under the Affordable Care Act
.
JAMA
.
2015
;
314
(
4
):
366
374
28
Lee
H
,
Porell
FW
.
The effect of the Affordable Care Act Medicaid expansion on disparities in access to care and health status [published online ahead of print October 26, 2018]
.
Med Care Res Rev
.
doi:10.1177/1077558718808709
29
Courtemanche
C
,
Marton
J
,
Ukert
B
,
Yelowitz
A
,
Zapata
D
.
Effects of the Affordable Care Act on health behaviors after three years
.
2018
. Available at: www.nber.org/papers/w24511. Accessed April 23, 2018
30
Long
SK
,
Bart
L
,
Karpman
M
,
Shartzer
A
,
Zuckerman
S
.
Sustained gains in coverage, access, and affordability under the ACA: a 2017 update
.
Health Aff (Millwood)
.
2017
;
36
(
9
):
1656
1662
31
McMorrow
S
,
Gates
JA
,
Long
SK
,
Kenney
GM
.
Medicaid expansion increased coverage, improved affordability, and reduced psychological distress for low-income parents
.
Health Aff (Millwood)
.
2017
;
36
(
5
):
808
818
32
Johnston
EM
,
Strahan
AE
,
Joski
P
,
Dunlop
AL
,
Adams
EK
.
Impacts of the Affordable Care Act’s Medicaid expansion on women of reproductive age: differences by parental status and state policies
.
Womens Health Issues
.
2018
;
28
(
2
):
122
129
33
Daw
JR
,
Sommers
BD
.
The Affordable Care Act and access to care for reproductive-aged and pregnant women in the United States, 2010–2016
.
Am J Public Health
.
2019
;
109
(
4
):
565
571
34
Wherry
LR
.
State Medicaid expansions for parents led to increased coverage and prenatal care utilization among pregnant mothers
.
Health Serv Res
.
2018
;
53
(
5
):
3569
3591
35
Johnston
EM
,
McMorrow
S
,
Thomas
T
,
Kenney
GM
.
Racial disparities in uninsurance among new mothers following the Affordable Care Act.
2019
. Available at: https://www.urban.org/research/publication/racial-disparities-uninsurance-among-new-mothers-following-affordable-care-act. Accessed August 9, 2019
36
Daw
JR
,
Kozhimannil
KB
,
Admon
LK
.
High rates of perinatal insurance churn persist after the ACA
. Available at: https://www.healthaffairs.org/do/10.1377/hblog20190913.387157/full/. Accessed September 20, 2019
37
Ruggles
S
,
Flood
S
,
Goeken
R
, et al
.
IPUMS USA: Version 9.0
.
Minneapolis, MN
:
IPUMS
;
2019
38
Lynch
V
,
Kenney
GM
,
Haley
J
,
Resnick
DM
.
Improving the Validity of the Medicaid/CHIP Estimates on the American Community Survey: The Role of Logical Coverage Edits
.
Suitland, MD
:
US Census Bureau
;
2011
39
State Health Access Data Assistance Center
.
Using SHADAC Health Insurance Unit (HIU) and Federal Poverty Guideline (FPG) microdata variables
.
2013
. Available at: www.shadac.org/publications/using-shadac-health-insurance-unit-hiu-and-federal-poverty-guideline-fpg-microdata. Accessed December 5, 2018
40
Flood
S
,
King
M
,
Ruggles
S
,
Warren
JR
.
Integrated Public Use Microdata Series, Current Population Survey: Version 5.0
.
Minneapolis, MN
:
University of Minnesota
;
2015
42
Medicaid and CHIP Payment Access Commission
.
Medicaid expansion to the new adult group
. Available at: https://www.macpac.gov/subtopic/medicaid-expansion/. Accessed September 13, 2019
43
US Census Bureau
.
Investigating the 2010 undercount of young children – examining coverage in demographic surveys
. Available at: https://www.census.gov/programs-surveys/decennial-census/2020-census/planning-management/final-analysis/2020-report-2010-undercount-children-examining-coverage-demo-surveys.html. Accessed August 21, 2019
44
Li
R
,
Bauman
B
,
D’Angelo
DV
, et al
.
Affordable Care Act-dependent insurance coverage and access to care among young adult women with a recent live birth
.
Med Care
.
2019
;
57
(
2
):
109
114
45
Buchmueller
TC
,
Levinson
ZM
,
Levy
HG
,
Wolfe
BL
.
Effect of the Affordable Care Act on racial and ethnic disparities in health insurance coverage
.
Am J Public Health
.
2016
;
106
(
8
):
1416
1421
46
Searing
A
,
Cohen Ross
D.
Medicaid expansion fills gaps in maternal health coverage leading to healthier mothers and babies.
2019
. Available at: https://ccf.georgetown.edu/2019/05/09/medicaid-expansion-fills-gaps-in-maternal-health-coverage-leading-to-healthier-mothers-and-babies/. Accessed May 23, 2019
47
Selden
TM
,
Lipton
BJ
,
Decker
SL
.
Medicaid expansion and marketplace eligibility both increased coverage, with trade-offs in access, affordability
.
Health Aff (Millwood)
.
2017
;
36
(
12
):
2069
2077
48
Sommers
BD
,
Gourevitch
R
,
Maylone
B
,
Blendon
RJ
,
Epstein
AM
.
Insurance churning rates for low-income adults under health reform: lower than expected but still harmful for many
.
Health Aff (Millwood)
.
2016
;
35
(
10
):
1816
1824
49
Brooks
T
.
What some researchers get wrong about Medicaid’s income eligibility requirements
. Available at: https://www.healthaffairs.org/do/10.1377/hblog20190918.358911/full/. Accessed September 27, 2019

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

Supplementary data