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Preconception, Pregnancy, and Infant Health Post Medicaid Expansion

A woman giving birth in the United States is 50% more likely to deliver preterm compared to a woman in Canada or the United Kingdom (OECD, 2016). Scholars and public health officials have long hypothesized that increased access to prenatal care would lower the rates of adverse birth outcomes seen in the US to levels seen in other developed nations (IOM, 1985). While the expansion of Medicaid to cover low-income pregnant women in the 1980s and ‘90s did increase access to prenatal care, its impacts on adverse birth outcomes were marginal (Dave et al., 2008; Howell, 2001). There is now growing recognition that preventive care during the prenatal period is often too late to reduce risks from factors such as smoking, alcohol use, poor nutrition, chronic disease, and unintended pregnancy (all of which increase the risk for adverse birth outcomes). Instead, preconception care may be key to improving women’s health at the outset of pregnancy and subsequently decreasing rates of adverse birth outcomes (Atrash et al., 2008; March of Dimes, 2002; ACOG, 2005; Johnson et al., 2006). However, prior to the expansion of Medicaid under the Affordable Care Act (ACA) in 2014, over one-third of low-income women of reproductive age in the United States lacked health insurance and, thus, access to preventive healthcare during the preconception phase of their lives.

The expansion of Medicaid under the Affordable Care Act (ACA) allowed states to expand coverage to all non-elderly Americans with incomes up to 138% of the federal poverty level (FPL). However, due to a 2012 U.S. Supreme Court ruling, not all states have expanded coverage; by January 2014, only 20 states had expanded Medicaid under the ACA and several states expanded coverage in later years. This state-level variation in the 2014 Medicaid Expansion under the ACA offers a unique natural experiment within which to test the hypothesis that increasing health care coverage for low-income women can improve preconception health care access, utilization of preventive care, chronic disease management, overall health, and health behaviors. Thus, the goal of the proposed research was to determine the impacts of the ACA Medicaid expansion on prevalence of these outcomes among low-income women of reproductive age living in states that expanded Medicaid and similar women in states that did not expand Medicaid.

According to our analytical findings, and several recent publications, the ACA Medicaid expansion has led to increased health insurance coverage for low-income women of reproductive age (Johnston et al., 2018; Wehby and Lyu, 2018; Simon et al., 2017). Moreover, the increase in insurance due to the ACA Medicaid expansion increased the use of healthcare services that have the potential to improve maternal preconception health and subsequent pregnancy health, including increased use of prescription medications for contraception and smoking cessation as well as testing, diagnosis and treatment of chronic diseases (Wherry and Miller, 2016; Maclean et al., 2017; Ghosh et al., 2017). Our research is the first work of its kind to examine whether the gains in health care coverage due to Medicaid expansion have translated to improved health among women of reproductive age in domains known to be associated with pregnancy health, such as chronic disease management, smoking, alcohol use, and obesity.

To this end, our approach was to examine the Behavioral Risk Factor Surveillance System (BRFSS) dataset using a quasi-experimental research design, exploiting the state-to-state variation in Medicaid expansion and eligibility in a rigorous and innovative empirical approach

Data from this research project demonstrated that the Medicaid expansion was significantly associated with increased likelihood of having health insurance, having had a pap test in the last 3 years, taking blood pressure medication if diagnosed with hypertension, and taking insulin if diagnosed with diabetes. Furthermore, our research shows that the Medicaid expansion was significantly associated with decreases in heavy drinking and avoiding health care due to cost. The expansion did not appear to impact other measures of preventive health care, days not in good physical or mental health, smoking cessation attempts or BMI. These improvements were largest among women with no dependent children and married women.

As such, the ACA Medicaid expansion has the potential to significantly improve preconception health and consequently, to improve the health of women of reproductive age, pregnant women, and infants. Therefore, national and statewide policy efforts must aim to expand, maintain, and sustain Medicaid coverage, particularly for these populations. Our research group will continue seeking to understand the impacts of Medicaid expansion on pregnancy health and birth outcomes in future work.