Family Values Means Covering Families: Parents Need to Focus on Parenting, Not Access to Care

Child health depends on family health. In this issue of Pediatrics, Johnston et al¹  clearly illustrate challenges facing low-income mothers in gaining access to health insurance during the first year after childbirth. Although highlighting the positive impact of Medicaid expansion through the Patient Protection and Affordable Care Act (in some states), the number of mothers who are uninsured before, during, and after pregnancy in the United States is alarming.

Of 185 World Health Organization member states with a population >100 000, the United States and the Dominican Republic were the only countries where maternal mortality increased between 2000 and 2017.²  Women with preexisting chronic conditions, living in poverty, and belonging to a racial and/or ethnic minority are disproportionately affected.³  Studies of women who have delivered a child have found that one-quarter were uninsured in the month before pregnancy, and more than half of the mothers had <12 years of education.⁴ 

Johnston et al¹  draw attention to this critical issue while elucidating a partial solution: expanding access to health insurance through the Medicaid program. Not surprisingly, they found that Medicaid-expansion states experienced significant decreases in uninsurance among new mothers living in poverty. They also found that these increases were more robust than increases in access to subsidized private insurance in nonexpansion states. Their rigorous study includes a detailed description of the methodology, assumptions, and sensitivity analyses they employed to bolster confidence in the reliability of their findings. Although this is an important contribution, the big picture is that the United States needs to do more to fill gaps in insurance coverage for new parents.

According to Johnston et al,¹  there were ∼451 000 uninsured new mothers in the United States in 2017.¹  This number is striking because new mothers are particularly vulnerable to falling through the cracks at a time when detrimental health outcomes not only affect them but also may negatively affect the health, development, and wellbeing of their children. Furthermore, this analysis acknowledges thousands of low-income women in the United States who are not eligible for Medicaid at all. From effectively managing chronic diseases in the postpartum period to addressing physical and behavioral health conditions that are directly associated with childbearing (eg, postpartum depression), a new mother’s health has critical implications for her and her family.

Postpartum depression is one quintessential example in which addressing maternal health is critical to ensuring effective, engaged, healthy parenting. Proactively supporting health for a family’s next pregnancy and across multiple generations is necessary to disrupt the intergenerational cycle of disadvantage.⁵  This study highlights how state and federal programs aimed at insuring the poor still fall short.

Finally, insurance coverage is necessary but not sufficient to guarantee access to appropriate, timely, or high-quality health care. The voltage drop framework introduced by Eisenberg and Power⁶  outlines 7 steps from insurance to health care: (1) insurance is available; (2) insurance enrollment; (3) providers and services are covered; (4) informed choice of plans, clinicians, and health care institutions is available; (5) consistent source of primary care is available; (6) referral services are accessible; and (7) high-quality care is delivered. Each of these steps is critical in the pursuit of health care for families.⁷  The steps to health must also ensure that every child and family has what they need to achieve optimal development and wellbeing.

How can pediatric professionals strengthen family health? First, we must value parents and continue to champion investments in parents as critical investments in children, who are 100% of the future. Multiple screening tools are available and have proven to be helpful in identifying the threats to children’s health that are associated with failure to meet the health and social needs of families.^8,9  The American Academy of Pediatrics recommends screening for parental smoking, maternal depression, and intimate partner violence to improve health for both parents and children.^10–13  Second, we must advocate for women’s access to high-quality preconception and interconception health care as a part of pediatric care. Addressing women’s access to care, reproductive planning, nutrition, substance use, and mental health can enhance women’s ability to nurture their children, improve health in future pregnancies, and support overall family health.^14,15  Research suggests that preconception health screening and brief intervention in pediatric primary care for women is feasible and improves outcomes associated with healthy mothers and infants, such as women’s folate use and quitting smoking.¹⁶  Finally, we must continue to advocate for insurance coverage, access to high-quality care, and demonstrable, purposeful, and significant investment in supporting new parents. This includes approaches to reduce child poverty by investing in programs that support low-income families beyond access to insurance.¹⁷  Such efforts will help address fundamental causes that contribute to health inequities across the lifespan.

Healthy mothers and families before, during, and after pregnancy are essential for healthy children and a healthy society. Maternal insurance coverage, morbidity, and mortality are not just issues for obstetrics or pediatrics but are sentinel measures of our nation’s health. We must do better.