Continuous Marketplace Coverage Led to Increased Prenatal Care Use

Affordable Care Act (ACA) Marketplace coverage for pregnant people before, during, and after pregnancy was associated with higher rates of prenatal care use compared to people who had discontinuous coverage, a Health Affairs study found.

Twelve million Americans receive health insurance through the Marketplace as of 2021. Under the ACA, maternity care is listed as one of the essential health benefits that all Marketplace plans must offer members.

But pregnancy is not included as a qualifying life event that permits individuals to enroll in Marketplace coverage outside of the annual enrollment period. Pregnant people who wish to enroll in a plan must either wait for the enrollment period or wait until they give birth, which is considered a qualifying event for early coverage.

Discontinuous healthcare coverage has been associated with delays in care, lower likelihood of having a regular source of care, and increased emergency department use, the report noted.

Researchers from Boston University School of Public Health looked at data from the Pregnancy Risk Surveillance and Monitoring System (PRAMS) between 2016 and 2018 to learn how often pregnant people had continuous marketplace coverage throughout pregnancy and if the coverage patterns had any effect on their prenatal care use.

They found that 6,491 pregnant people reported having Marketplace coverage before, during, or after pregnancy.

The researchers defined continuous coverage as being enrolled from preconception to postpartum, while discontinuous coverage referred to individuals who were not enrolled preconception but enrolled during pregnancy.

Around one-third of individuals had continuous coverage from preconception to postpartum. More than half (66.4 percent) had coverage preconception but did not maintain it the whole time. Around 20 percent of individuals enrolled in Marketplace coverage during their pregnancy and 11.3 percent had coverage only after they had given birth.

For the individuals who did not have continuous Marketplace coverage throughout pregnancy, Medicaid was a common replacement.

Of the people who only had Marketplace coverage before their pregnancy, 71.5 percent reported having Medicaid coverage during their pregnancy. Among the people who had Marketplace coverage after their pregnancy only, 49.8 percent had Medicaid coverage during pregnancy.

Individuals may have switched to Medicaid after becoming pregnant due to the higher income limits, lower cost-sharing, and smaller premiums compared to Marketplace plans.

They used the Adequacy of Prenatal Care Utilization Index to quantify prenatal care use. The index uses the date of the first prenatal care visit, length of gestation, and the number of visits to produce a number ranging from one, indicating inadequate, to four, which indicates adequate plus.

More than half (68 percent) of the individuals who had continuous Marketplace coverage had a preconception healthcare visit, according to the report. Slightly fewer (54 percent) individuals with discontinuous coverage could say the same.

Nearly 80 percent of individuals with continuous prenatal coverage through the Marketplace experienced adequate or more than adequate prenatal care use, compared to 70.3 percent of those who had discontinuous coverage.

People with continuous coverage were also slightly more likely to attend their first prenatal visit during the first trimester than people with discontinuous coverage (89.4 and 84 percent, respectively). Additionally, for those who enrolled in coverage during their pregnancy, there was a lower rate of attending the recommended twelve or more prenatal visits.

The Health Affairs report findings suggest that policymakers might consider making Marketplace coverage more accessible to pregnant people, as continuous coverage was associated with higher prenatal care use. Continuous coverage may also increase the chances of individuals having affordable access to maternal healthcare.

“Making it easier for pregnant people to enroll in Marketplace coverage at an early stage of pregnancy, potentially by designating pregnancy as a qualifying life event on the federal Marketplace and increasing the number of state-based Marketplaces that take this approach, could facilitate continuity of coverage for this population,” the report concluded.

Other studies have shown that other key actions, such as expanding Medicaid, may also improve prenatal care. One study found that pregnant individuals in Medicaid expansion states were more likely to have Medicaid coverage preconception and less likely to have preconception depression compared to those in states that have not expanded Medicaid.