Does Medicaid Expansion Impact Postpartum Coverage, Outpatient Visits, and Racial Disparities?

Why This Study Is Important

Researchers found that Medicaid expansion can increase postpartum coverage and outpatient postpartum care visits among low-income individuals, while narrowing racial and ethnic disparities in coverage, contributing new findings to the association between expansion and health care utilization. These findings are notable given that, when compared to other high-income countries, the US has the highest maternal mortality rate, driven largely by racial disparities. More than 50% of maternal deaths occur after childbirth, during the postpartum period, when many women experience gaps in insurance coverage. Policymakers have focused efforts on expanding health care coverage during this period through Medicaid expansion, or pregnancy Medicaid extension through one year postpartum, as postpartum insurance gaps are much higher among those covered by Medicaid than a commercial payer.

What This Study Found

• Medicaid expansion was associated with a 27.8 percentage point increase in continuous postpartum coverage during the first six months post-childbirth among those covered by Medicaid, representing a 54.9% relative increase. Similarly large increases in postpartum coverage and visits were reported among Black and White individuals.
• Among those covered by Medicaid at childbirth, expansion led to a 0.9 increase in postpartum visits during the first 6 months post-childbirth. Compared with the pre-expansion period visit rate of 1.2 visits within the first 6 months postpartum, after expansion there was a 75.0% relative increase in visits.
• In a pre- and post-expansion analysis combining those with Medicaid and those with childbirth covered by a commercial payer, researchers found that the disparity between non-Hispanic Black and White women in continuous 6-month postpartum coverage was eliminated. However, for postpartum outpatient visits, disparities persisted.

What These Findings Mean

Lack of continuous insurance coverage after childbirth is a critical driver of health care utilization inequities between commercial and Medicaid-paid births. Medicaid expansion greatly reduced the gap in continuous insurance coverage and non-emergency department outpatient visits during the first 6-months postpartum between commercially paid and Medicaid paid births.

Given these findings, increased availability of Medicaid through expansion has the potential to be an influential and effective policy tool to increase both coverage and outpatient health care use during the postpartum period among low-income individuals in states that have not yet expanded Medicaid. However, increased coverage may not be sufficient to reduce existing racial disparities in outpatient postpartum care; therefore, additional policy efforts that focus on addressing institutional and interpersonal racism may be needed. To improve maternal health equity, future legislative efforts, in conjunction with expansion, may need to target determinants of care use, such as paid leave, improved housing and transportation, diversity in the perinatal workforce, and improved health care quality.

More About This Study

The main analysis in this study was conducted through a quasi-experimental differences-in-differences model to evaluate 60,990 births in Arkansas from 2013 to 2015. Of these births, 72.2% were paid for by Medicaid, with the remaining births paid for by a commercial payer. Researchers assessed changes in racial disparities, postpartum insurance, and postpartum care by utilizing birth certificates linked to medical claims from Arkansas’ All-Payer Claim Database. This data allowed for the examination of changes among postpartum adults with Medicaid financed births before (January through June 2013) and after expansion (January 2014 through December 2015) compared with concurrent trends among postpartum adults with commercially financed births.

For more information about this study, contact Dr. Maria Steenland at maria_steenland@brown.edu. For more information about the NIHCM Foundation Investigator-Initiated Research Grant Program, contact Cait Ellis at cellis@nihcm.org.