New Mothers Experience Uninsurance, Care Disparities Post-ACA

Although recent studies have heralded the Affordable Care Act’s ability to provide more generous insurance options for new mothers, Medicaid expansion perinatal and postpartum policies may still leave low-income new mothers uninsured and facing care disparities, a recent study published in Health Affairs suggested.

“Medicaid has a long history of serving pregnant women, but many women are not eligible for Medicaid before pregnancy or after sixty days postpartum,” the study began. “Together, our findings indicate that despite recent coverage gains, further policy change is needed to help women maintain health insurance coverage before and after pregnancy and to allow them to address ongoing health issues including obesity and depression.”

In 2020 alone, a few key studies emphasized the impact that the Affordable Care Act has had on women’s healthcare in general and coverage for low-income pregnant women specifically.

These studies showed that longer postpartum Medicaid coverage could prevent maternal uninsurance, Medicaid expansion helped identify prenatal and postpartum indicators, Medicaid expansion improved utilization of postpartum care, and Medicaid expansion reduced unwanted pregnancies through access to contraceptives.

“Despite significant improvements under the ACA, however, churning into and out of coverage and between types of coverage persists, many women remain uninsured before and after their pregnancies, and those who are uninsured face significant health problems,” the study stated.

The researchers leveraged data from 2015 to 2018 spanning 43 states that participated in the Pregnancy Risk Assessment Monitoring System (PRAMS). The system analyzed perinatal uninsurance and health outcomes for uninsured new mothers.

Over a quarter of the participating new mothers (26.8 percent) had no insurance prior to becoming pregnant. After giving birth, more than one in five women (21.9 percent) became uninsured. More than a third (34.5 percent) had uninsurance in either the perinatal or the postpartum stages.

Not all of the states in the PRAMS assessment were Medicaid states. The distinction between Medicaid expansion and nonexpansion states was visible in the data.

In expansion states, slightly more than 17 percent of women who received Medicaid coverage for prenatal care were uninsured before conception and 10 percent of women who received Medicaid coverage for prenatal care became uninsured postpartum.

In nonexpansion states, the percentage of women who fit this description and who had no insurance prior to conception was more than double the percentage in Medicaid expansion states (38.1 percent). And the percentage that became uninsured postpartum was almost four times as large (36.1 percent).

Ultimately, slightly more than 50 percent of pregnant women in nonexpansion states were uninsured before or after their pregnancy, while those in expansion states were 21 percent likely to have been uninsured.

In expansion states, women who had ever experienced uninsurance in their pregnancy were more likely to have only experienced it in the perinatal phase, as opposed to women in nonexpansion states who were more likely to have been uninsured both before and after the pregnancy.

Although Medicaid expansion states did display lower rates of uninsurance among new mothers, the researchers noted that the number of women who experienced uninsurance before or after pregnancy was still significant.

“Despite coverage provisions including Medicaid expansion and subsidized Marketplace coverage, we found that more than one-third of mothers with Medicaid for prenatal care were uninsured either before they became pregnant or in the two to six months postpartum in the years after ACA implementation,” the researchers stated.

The study also found that Medicaid expansion produced suboptimal results on reducing racial disparities.

Hispanic women reported the highest rate of uninsurance for all three measures in the Medicaid expansion states. This was particularly true for women who completed the survey in Spanish.

In nonexpansion states, Hispanic women also had a much higher rate of uninsurance. Black women had the lowest rate of uninsurance in both periods.

“In both expansion and nonexpansion states, disparities in uninsurance between Black and White women were relatively modest compared with the gaps between Hispanic women and each of these groups,” the study explained.

This data syncs with the results of a separate study which found that Medicaid expansion continued to produce mixed results on reducing racial care disparities ten years after the Affordable Care Act’s implementation.

Nevertheless, there were some positive results to report.

Based on the fact that perinatal uninsurance is more common than postpartum uninsurance, the researchers concluded that Medicaid expansion successfully channeled uninsured women into the Medicaid program and then helped them maintain coverage. This suggested that outreach during the perinatal stage could be particularly successful.

Introducing longer postpartum coverage could also help ease new mothers back into their employer-sponsored coverage as they return to work, the researchers recommended.