Medicaid Expansion May Improve Maternal Health Outcomes, Coverage

Policymakers may be able to improve maternal health and healthcare coverage around the time of pregnancy through Medicaid expansion, according to a recent Health Affairs report.

The researchers used data from state surveys included in the Pregnancy Risk Assessment Monitoring System (PRAMS) phases 7 (2012–15) and 8 (2016–18). Ultimately, the study involved almost 55,000 pre-pregnancy mental health observations from 17 states and nearly 57,000 postpartum mental health observations from 18 states.

“Before adjustment, Medicaid expansion was associated with increases in prepregnancy and postpartum Medicaid insurance coverage, declines in prepregnancy self-reported depression, and increases in prepregnancy screening and postpartum well-being,” the report explained.

According to the PRAMS data, 27 percent of the respondents stated that they had been screened for depression in the pre-pregnancy period. Sixteen percent of respondents reported having depression prior to pregnancy. Another 16 percent stated that they experienced depressive symptoms after pregnancy.

When comparing Medicaid expansion states with nonexpansion states, the experts found some noteworthy differences.

There was a 9.6 percentage point gap between the share of participants who had Medicaid coverage before being pregnant, with more individuals in states with Medicaid expansion having coverage. This means that individuals in a Medicaid expansion state were 22 percent more likely to have prepregnancy Medicaid coverage.

Respondents also reported a lower rate of prepregnancy depression in Medicaid expansion states (2.5 percentage points or 16.0 percent lower). 

Prepregnancy screening for depression was higher in Medicaid expansion states, but not significantly (2.3 percentage points or 9.0 percent). However, the share of pregnant persons who experienced prepregnancy depression changed over time in Medicaid expansion states, improving each year after the enactment of Medicaid expansion.

Medicaid expansion may have amplified coverage for preventive care services, including screenings, during the period between births. 

The researchers noted that self-reported depression was more frequently reported among pregnant persons who had no prior history of a live birth. In contrast, participants who had experienced a live birth in the past were more likely to engage in prepregnancy screenings.

Despite these strides in coverage and mental health conditions’ prevalence, the study found no significant adjustments to postpartum depression or well-being that could be tied to Medicaid expansion. Medicaid expansion increased postpartum coverage by nine percentage points. 

Also, there was little evidence regarding whether Medicaid enrollment followed the same improving trajectory as the share of pregnant persons experiencing prepregnancy depression.

The researchers deduced that the decrease in self-reported depression in Medicaid expansion states may be the result of more frequent prepregnancy depression screenings. These findings would align with previous research on the topic, if so.

“Our study is the first to examine whether the ACA Medicaid expansions affected prepregnancy or postpartum mental health and well-being,” the researchers noted. 

“Using data from PRAMS, the only national source of data collected from people who recently had a live birth, we showed that Medicaid expansion was associated with a decline in self-reported prepregnancy depression that increased with time since expansion. Expanding health insurance coverage to low-income people before pregnancy may improve perinatal mental health.”

The results of this report coincided with previous data on the impact that Medicaid expansion can have on preventive care service utilization among pregnant persons. Low-income women in Medicaid expansion states were more likely to undergo preconception health consultations, take prenatal folic acid daily, and use contraception in the postpartum period.

However, other research has indicated that one in three new mothers on Medicaid still experience uninsurance for some period of time, either before or following their pregnancy.

In 2020, researchers determined that extending postpartum Medicaid insurance could improve outcomes among new mothers. While most of the uninsured mothers did receive a postpartum checkup, many had conditions that needed long-term care, which new mothers might forego if they did not have health insurance.

Experts continue to call for policymakers to extend health insurance coverage to low-income pregnant persons to improve health outcomes.