Post-ACA, More Than One-third Of Women with Prenatal Medicaid Remained Uninsured Before or After Pregnancy

Overview

Since the early 1990s, Medicaid has been critical in providing insurance coverage for pregnant women with low incomes in the United States - pregnancy-related Medicaid coverage is available to women with incomes up to 200 percent of the federal poverty level in most states. Because pregnancy-related Medicaid eligibility is almost always more generous than eligibility for other adults, many women with low incomes not otherwise eligible for Medicaid gain coverage during their pregnancies but then lose that coverage sixty days after delivery, when their pregnancy-related eligibility expires. The American Rescue Plan Act of 2021 included an option for states to extend Medicaid coverage for twelve months postpartum. While the ACA provided coverage improvements for pregnant women outside of pregnancy, especially in states expanding Medicaid, many low-income women remain uninsured before or after their pregnancies. Building on existing studies tracking changes in Medicaid coverage and uninsurance under the law, researchers Emily M. Johnston, Stacey McMorrow, Clara Alvarez Caraveo and Lisa Dubay examined data for new mothers with Medicaid-covered prenatal care in this study published in Health Affairs.

Findings

Drawing on data for new mothers with Medicaid-covered prenatal care in 2015–18 from forty-three states participating in the Pregnancy Risk Assessment Monitoring System (PRAMS), the research team evaluated patterns of perinatal uninsurance and health outcomes of women experiencing uninsurance to better understand how different Medicaid policies may address coverage barriers. They found:

• 26.8 percent of new mothers were uninsured before pregnancy, 21.9 percent became uninsured two to six months postpartum, and 34.5 percent were uninsured in either period. 
• These patterns varied between Medicaid expansion states and nonexpansion states:
  • 21.0 percent became uninsured at some point during the perinatal period in expansion states compared with 50.6 percent in nonexpansion states.

Implications for Policy and Practice

These findings indicate that women experience uninsurance surrounding pregnancy, both pre-conception and postpartum, highlighting a lack of accessible public and private coverage options outside pregnancy. To increase coverage for these mothers, the researchers suggest:

• Increased outreach and enrollment efforts to Medicaid eligible women before pregnancy, particularly in expansion states.
• Outreach and enrollment efforts for subsidized Marketplace coverage to help women not eligible for Medicaid identify affordable coverage options.
• Expanded coverage options for women outside of pregnancy, such as take up of Medicaid expansion by additional states or take up of the ARP’s postpartum extension of pregnancy-related eligibility.