Study finds increase in preconception health coverage after Medicaid expansion

The number of low-income women enrolled in Medicaid before becoming pregnant rose substantially in states that expanded Medicaid eligibility through the Affordable Care Act, according to researchers at Columbia University Mailman School of Public Health. The results are published online in the journal of Obstetrics & Gynecology.

"This study suggests that the ACA Medicaid expansion was associated with improved continuity of Medicaid coverage from the preconception to prenatal period," said Jamie Daw, PhD, assistant professor of Health Policy and Management at the Columbia Mailman School. "Higher rates of health insurance before pregnancy may improve access to preconception care, which can help women to appropriately plan their pregnancy and optimize their health before conceiving. Interventions in the preconception period such as disease screening, disease management, and exposure avoidance counseling reduce pregnancy risks and are associated with improved maternal and fetal outcomes."

The study focused on women with family incomes 138 percent of the federal poverty level or less who participated in the Pregnancy Risk Assessment Monitoring System from 2009 to 2015. The study sample included 30,495 women from eight states that expanded Medicaid on January 1, 2014, under the Affordable Care Act and 26,561 patients from seven states that did not.

The researchers found rates of preconception Medicaid coverage (the month before conception) increased from 31 percent to 36 percent in non-expansion states, and rose from 43 percent pre-policy to 57 percent in expansion states after the policy was implemented. Adjusting for maternal characteristics and unemployment rates, preconception Medicaid coverage rose by an additional 9 percentage-points in expansion states relative to non-expansion states. This represents a 20 percent increase from baseline in expansion states. Before the ACA, an estimated 25 percent of reproductive-aged women in the U.S. reported no insurance in the past year and the income eligibility for Medicaid for non-pregnant women varied widely by state.

About half of the increase in Medicaid coverage was driven by a decrease in the number of women with private insurance. The other half of the increase in Medicaid was among uninsured women. Prior research by Daw and colleagues showed that before the ACA more than half of women with pregnancy-related Medicaid were uninsured prior to pregnancy.

"The U.S. has the highest maternal and infant mortality rate among high-income countries," said Daw. "More research is needed to explore the extent to which the increases in preconception Medicaid found in this study led to improvements in health outcomes for mothers and children."