Medicaid Expansion Increased Preconception Health Counseling, Folic Acid Intake, and Postpartum Contraception

Overview

The period before pregnancy is critically important for the health of a woman and her infant, yet not all women have access to health insurance during this time. Rebecca Myerson of the University of Wisconsin-Madison, Samuel Crawford of the University of Southern California, and Laura R. Wherry of New York University evaluated whether increased access to health insurance under the Affordable Care Act (ACA) Medicaid expansions affected ten preconception health indicators, including the prevalence of chronic conditions and health behaviors, birth control use and pregnancy intention, and the receipt of preconception health services.

Findings

Using data from the 2011-2018 Behavioral Risk Factor Surveillance System and the 2011-2017 Pregnancy Risk Assessment Monitoring System, the research team compared changes in outcomes for low-income women in both expansion and non-expansion states following the ACA Medicaid expansions.

They found significant improvements in the following three preconception health indicators associated with the Medicaid expansions:

• A 4-percentage point increase in the share of women reporting a preconception health conversation with a health care provider before pregnancy, or a 22 percent increase over the baseline mean.
• An increase in the share of women reporting daily folic acid intake in the month before pregnancy of 1.9 percentage points, or a 9.7 percent increase over the baseline rate.
• An increase in the use of effective methods of contraception during the postpartum period of 3.8 percentage points, or a 7.1 percent increase over baseline.

The authors did not detect significant changes on the other indicators studied, which were primarily related to chronic disease prevalence or other health behaviors.

Implications for Policy and Practice

This paper provides new evidence that expanded Medicaid coverage led to improvements in addressing certain preconception health risks among low-income women. First, the researchers found increased receipt of preconception health counseling, which provides a valuable opportunity to address key risk factors associated with adverse maternal and infant health outcomes prior to conception. Second, the research team documented an increase in daily folic acid intake prior to pregnancy, which is recommended for all women by the U.S. Preventive Services Task Force to reduce the likelihood of neural tube defects among newborns. Third, they documented increased use of effective birth control methods after childbirth, which may decrease the likelihood of unplanned pregnancies or short interpregnancy intervals.  

These findings demonstrate that insurance expansions under the ACA can help address some of the risk factors that shape maternal and child health in the U.S. The findings also indicate that expanded Medicaid coverage affects postpartum health care use among recent mothers, which suggests that extensions in postpartum Medicaid coverage under recent legislative proposals may help promote the receipt of recommended postpartum care.