ACA Medicaid Expansion and Insurance Coverage Among New Mothers Living in Poverty

Association of Medicaid expansion with birth outcomes: evidence from a natural experiment in Texas

BACKGROUND

Empirical evidence on the effects of Medicaid expansion is mixed and highly state-dependent. The objective of this study is to examine the association of Medicaid expansion with preterm birth and low birth weight, which are linked to a higher risk of infant mortality and chronic health conditions throughout life, providing evidence from a non-expansion state, overall and by race/ethnicity.

METHODS

We used the newborn patient records obtained from Texas Public Use Data Files from 2010 to 2019 for hospitals in Texarkana, which is located on the border of Texas and Arkansas, with all of the hospitals serving pregnancy and childbirth patients on the Texas side of the border. We employed difference-in-differences models to estimate the effect of Medicaid expansion on birth outcomes (preterm birth and low birth weight) overall and by race/ethnicity. Newborns from Arkansas (expanded Medicaid in 2014) constituted the treatment group, while those from Texas (did not adopt the expansion) were the control group. We utilized a difference-in-differences event study framework to examine the gradual impact of the Medicaid expansion on birth outcomes.

RESULTS

Medicaid expansion was associated with a 1.38-percentage-point decrease (95% confidence interval (CI), 0.09-2.67) in preterm birth overall. Event study results suggest that preterm births decreased gradually over time. Medicaid expansion was associated with a 2.04-percentage-point decrease (95% CI, 0.24-3.85) in preterm birth and a 1.75-percentage-point decrease (95% CI, 0.42-3.08) in low birth weight for White infants. However, Medicaid expansion was not associated with significant changes in birth outcomes for other race/ethnicity groups.  CONCLUSIONS: Our findings suggest that Medicaid expansion in Texas can potentially improve birth outcomes. However, bridging racial disparities in birth outcomes might require further efforts such as promoting preconception and prenatal care, especially among the Black population.

The association of the Affordable Care Act with nutrient consumption in adults in the United States

The Patient Protection and Affordable Care Act, more commonly known as the ACA, was legislation passed in the United States in 2010 to expand access to health insurance coverage for millions of Americans with a key emphasis on preventive care. Nutrition plays a critical role in overall wellness, disease prevention and resilience to chronic illness but prior to the ACA many Americans did not have adequate health insurance coverage to ensure proper nutrition. With passage of the ACA, more individuals received access to nutritional counseling through their primary care physicians as well as prescription vitamins and supplements free of charge. The objective of this study was to evaluate the impact of a national health insurance reform on nutrient intake among general population, including more vulnerable low-income individuals and patients with chronic conditions. Using data from the National Health and Nutrition Examination Survey (NHANES), we identified 8,443 adults aged 21 years and older who participated in the survey before (2011-2012) and after the ACA (2015-2016) implementation and conducted a subgroup analysis of 952 respondents who identified as Medicaid beneficiaries and 719 patients with a history of cancer. Using pre-post study design and bivariate and multivariable logistic analyses, we compared nutrient intake from food and supplementation before and after the ACA and identified risk factors for inadequate intake. Our results suggest that intake of micronutrients found in nutrient-dense foods, mainly fruit and vegetables, has not changed significantly after the ACA. However, overall use of nutritional supplements increased after the ACA (p = 0.05), particularly magnesium (OR = 1.02), potassium (OR = 0.76), vitamin D (both D2, and D3, OR = 1.34), vitamin K (OR = 1.15) and zinc (OR = 0.83), for the general population as well as those in our subgroup analysis Cancer Survivors and Medicaid Recipients. Given the association of increased use of nutritional supplements and expansion of insurance access, particularly in our subgroup analysis, more research is necessary to understand the effect of increasing access to nutritional supplements on the overall intake of micro- and macronutrients to meet daily nutritional recommended allowances.

Association of Medicaid Expansion Under the Affordable Care Act With Medicaid Coverage in the Prepregnancy, Prenatal, and Postpartum Periods

INTRODUCTION

We evaluated how the Affordable Care Act (ACA) Medicaid eligibility expansion affected perinatal insurance coverage patterns for Medicaid-enrolled beneficiaries who gave birth overall and by race/ethnicity. We also examined state-level heterogeneous impacts.

METHODS

Using the 2011-2013 Medicaid Analytic eXtract and the 2016-2018 Transformed Medicaid Statistical Information System Analytic File databases, we identified 1.4 million beneficiaries giving birth in 2012 (pre-ACA expansion cohort) and 1.5 million in 2017 (post-ACA expansion cohort). We constructed monthly coverage rates for the two cohorts by state Medicaid expansion status and obtained difference-in-differences estimates of the association of Medicaid expansion with coverage overall and by race/ethnicity group (non-Hispanic White, non-Hispanic Black, and Hispanic). To explore state-level heterogeneous impacts, we divided the expansion and non-expansion states into groups based on the differences in the income eligibility limits for low-income parents in each state between 2012 and 2017.

RESULTS

Medicaid expansion was associated with 13 percentage points higher coverage in the 9 to 12 months before giving birth, and 11 percentage points higher coverage at 6 to 12 months postpartum. Hispanic birthing individuals had the greatest relative increases in coverage, followed by non-Hispanic White and non-Hispanic Black individuals. In Medicaid expansion states, those who experienced the greatest increases in income eligibility limits for low-income parents generally saw the greatest increases in coverage. In non-expansion states, there was less heterogeneity between state groupings.

CONCLUSIONS

Pregnancy-related Medicaid eligibility did not have major changes in the 2010s. However, states' adoption of ACA Medicaid expansion after 2012 was associated with increased Medicaid coverage before, during, and after pregnancy. The increases varied by race/ethnicity and across states.

Late Postpartum Coverage Loss Before COVID-19: Implications For Medicaid Unwinding

Using unique Pregnancy Risk Assessment Monitoring System follow-up data from before the COVID-19 pandemic, we found that only 68 percent of prenatal Medicaid enrollees maintained continuous Medicaid coverage through nine or ten months postpartum. Of the prenatal Medicaid enrollees who lost coverage in the early postpartum period, two-thirds remained uninsured nine to ten months postpartum. State postpartum Medicaid extensions could prevent a return to prepandemic rates of postpartum coverage loss.

Association of Medicaid Expansion With Postpartum Depression Treatment in Arkansas

Importance

Postpartum depression affects approximately 1 in every 8 postpartum individuals in the US. Antidepressant medication can effectively treat postpartum depression. However, gaps in postpartum insurance coverage after the end of Medicaid pregnancy coverage at 60 days postpartum may limit treatment uptake and decrease continuity of postpartum depression treatment.

Objective

To examine the association of Medicaid expansion in Arkansas with postpartum antidepressant prescription fills and antidepressant continuation and supply during the first 6 months postpartum.

Design, Setting, and Participants

Cohort study with a difference-in-differences analysis comparing persons with Medicaid and commercially financed childbirth using Arkansas' All-Payer Claims Database (2013-2016). Analysis was completed between July 2021 and June 2022.

Exposures

Medicaid-paid childbirth after January 1, 2014.

Main Outcomes and Measures

Antidepressant medication prescription fills and the number of days of antidepressant supply in the early (first 60 days after childbirth) and the late (61 days to 6 months after childbirth) postpartum periods.

Results

In this cohort study with a difference-in-differences analysis of 60 990 childbirths (mean [SD] birthing parent's age, 27 [5.3] years; 22% Black, 7% Hispanic, 67% White individuals), 72% of births were paid for by Medicaid and 28% were paid for by a commercial payer. Before expansion, 4.2% of people with a Medicaid-paid birth filled an antidepressant prescription in the later postpartum period. Medicaid expansion was associated with a 4.6 percentage point (95% CI, 2.9-6.3) increase in the likelihood, or a relative change of 110%, in this outcome. Before expansion, among people with postpartum depression in the early postpartum period with a Medicaid-paid birth, 32.7% filled an antidepressant prescription in the later postpartum period, and had an average of 23 days of antidepressant prescription supply during the later postpartum period. Among people with early postpartum depression, Medicaid expansion increased the continuity of antidepressant treatment by 20.5 percentage points (95% CI, 14.1-26.9) and the number of days with antidepressant supply in the later postpartum period by 14.1 days (95% CI, 7.2-20.9).

Conclusions and Relevance

Medicaid expansion in Arkansas was associated with an increase in postpartum antidepressant prescription fills, and an increase in antidepressant treatment continuity and medication supply in the period after Medicaid pregnancy-related eligibility ended.

Association of the affordable care act Medicaid expansions with postpartum contraceptive use and early postpartum pregnancy

OBJECTIVES

Before the Affordable Care Act (ACA), 55% of individuals giving birth with Medicaid lost insurance postpartum, potentially affecting their access to postpartum contraception. We evaluate the association of the ACA Medicaid expansions with postpartum contraceptive use and pregnancy at the time of the survey.

METHODS

We used 2012-2019 Pregnancy Risk Assessment Monitoring System data to estimate difference-in-difference models for the association of Medicaid expansions with the use of postpartum contraception (mean: 4 months postpartum): any contraception, long-acting reversible contraception, or LARC (contraceptive implant and intrauterine device), short-acting (contraceptive pill, patch, and ring), permanent, or non-prescription methods (condoms, rhythm method, and withdrawal), and pregnancy at the time of the survey. We examine low-income respondents overall and stratified by race and ethnicity.

RESULTS

We find that Medicaid expansion was associated with a 7.0 percentage point (95% CI: 3.0, 11.0) increase in postpartum LARC, a 3.1 percentage point (95% CI: -6.0, -0.2) decrease in short-acting contraception, and a 3.9 percentage point (95% CI: -6.2, -1.5) decrease in non-prescription contraceptive use overall. In stratified analyses, we find that increases in LARC use were concentrated among non-Hispanic White and Black respondents, with shifts in other postpartum contraceptives towards LARCs. Medicaid expansion was associated with a decrease in early postpartum pregnancy only among non-Hispanic Black respondents.

CONCLUSIONS

Medicaid expansions led to shifts from methods with a lower upfront out-of-pocket cost for people without insurance towards methods with the higher upfront out-of-pocket cost for people without insurance. These changes suggest that Medicaid expansion improved postpartum contraceptive access.

IMPLICATIONS

These findings indicate that postpartum uninsurance was a barrier to postpartum contraceptive access prior to Medicaid expansions under the Affordable Care Act. Medicaid expansions increased access to the full range of contraceptive methods.

State-level changes in health insurance coverage and parental substance use-associated foster care entry

For many families whose children are placed in foster care, initial contact with the child welfare system occurs due to interactions with the healthcare system, particularly in the context of the opioid epidemic and increased attention to prenatal drug exposure. In the last decade, many previously uninsured families have gained Medicaid health coverage, which has implications for their access to healthcare services and visibility to mandatory reporters. Using administrative foster care case data from the Adoption and Foster Care Analysis and Reporting System Foster Care Files and health insurance data from the American Community Survey, this study analyzes the associations between state-level health insurance coverage and rates of foster care entry due to parental substance use between 2009 and 2019. State-level fixed effects models revealed that public, but not private, health insurance rates were positively associated with rates of foster care entry due to parental substance use. These results support the hypothesis that health insurance coverage may promote greater contact with mandatory reporters among low-income parents with substance use disorders. Furthermore, this study illustrates how healthcare policy may have unintended consequences for the child welfare system.

Medicaid and moms: the potential impact of extending medicaid coverage to mothers for 1 year after delivery

The American Rescue Plan provides a pathway for states to expand postpartum Medicaid coverage for low-income mothers through 12 months after delivery. Data suggests that extension of post-partum Medicaid coverage should improve access to outpatient health care services, increase healthcare utilization, improve chronic disease management for at-risk mothers, and reduce disparities in care for racial/ethnic groups over-represented in Medicaid. Opportunities to provide increased preventive care for perinatal mood disorders and smoking cessation also exist. Further, this policy may reduce the burden of late maternal mortality. While improved access to contraceptive service postpartum provides a potential mechanism by which birth outcomes may improve, the effect of this policy on NICU admission, low birth weight (LBW) infants, and preterm birth is unknown. We discuss possible birth, infant and maternal health outcomes which may result from this expansion, drawing on data from the 2010 Medicaid Expansion via the Affordable Care Act.

Medicaid expansion and postpartum depressive symptoms: evidence from the 2009-2018 Pregnancy Risk Assessment Monitoring System survey

PURPOSE

This population-representative study examined the association of Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) with postpartum depressive symptoms among low-income women.

METHODS

We used data from the 2009 - 2018 Pregnancy Risk Assessment Monitoring System (PRAMS) surveys for 13 Medicaid expansion and 7 non-expansion states. We used a generalized difference-in-differences approach and log-binomial regression models to calculate prevalence ratios (PRs) and 95% confidence intervals (CIs) comparing the likelihood of postpartum depressive symptoms among low-income women (≤138% of the federal poverty level) who delivered in expansion and non-expansion states.

RESULTS

Adjusting for state and year fixed-effects and individual- and state-level confounders, low-income women who delivered in Medicaid expansion states had a decreased likelihood of postpartum depressive symptoms compared to low-income women who delivered in non-expansion states (PR = 0.93, 95% CI 0.80, 1.07). Results were largely consistent across multiple sensitivity analysis specifications. Results were robust to falsification tests among women with incomes >138% of the federal poverty level.

CONCLUSION

Our results indicate that Medicaid expansion may be associated with a small reduction in the likelihood of postpartum depressive symptoms. Future research should examine the potential for implementation of multiple supportive policies to achieve larger gains in treatment and prevention.

Catastrophic Health Expenditures With Pregnancy and Delivery in the United States

OBJECTIVE

To describe prevalence, trends, and risk factors for catastrophic health expenditures in the year of delivery among birth parents (delivering people).

METHODS

We conducted a retrospective, cross-sectional study of the Medical Expenditure Panel Survey from 2008-2016. We identified newborn birth parents and a 2:1 nearest-neighbor propensity-matched control cohort of nonpregnant reproductive-aged individuals, then assessed for catastrophic health expenditures (spending greater than 10% of family income) in the delivery year. We applied survey weights to extrapolate to the noninstitutionalized U.S. population and used the adjusted Wald test for significance testing. We compared risk of catastrophic health expenditures between birth parents and the control cohort and described time trends and risk factors for catastrophic spending with subgroup comparisons.

RESULTS

We analyzed 4,056 birth parents and 7,996 reproductive-aged females without pregnancy in a given year. Birth parents reported higher rates of unemployment (52.6% vs 46.6%, P<.001), and high rates of gaining (22.4%) and losing (25.6%) Medicaid in the delivery year. Birth parents were at higher risk of catastrophic health expenditures (excluding premiums: 9.2% vs 6.8%, odds ratio [OR] 1.95, 95% CI 1.61-2.34; including premiums: 21.3% vs 18.4%, OR 1.53, 95% CI 1.32-1.82). Birth parents living on low incomes had the highest risk of catastrophic health expenditures (18.8% vs 0.7% excluding premiums for 138% or less vs greater than 400% of the federal poverty level, relative risk [RR] 26.9; 29.8% vs 5.9% including premiums, RR 5.1). For birth parents living at low incomes, public insurance was associated with lower risks of catastrophic health expenditures than private insurance, particularly when including premium spending (incomes 138% of the federal poverty level or lower: 18.8% public vs 67.9% private, RR 0.28; incomes 139-250% of the federal poverty level: 6.5% public vs 41.1% private, RR 0.16). The risk of catastrophic spending for birth parents did not change significantly over time from before to after Affordable Care Act implementation.

CONCLUSION

Pregnancy and delivery are associated with increased risk of catastrophic health expenditures in the delivery year. Medicaid and public coverage were more protective from high out-of-pocket costs than private insurance, particularly among low-income families.

The ACA Medicaid Expansion And Perinatal Insurance, Health Care Use, And Health Outcomes: A Systematic Review

The Affordable Care Act (ACA) Medicaid expansion increased Medicaid eligibility for low-income adults regardless of their pregnancy or parental status. Variation in states' adoption of this expansion created a natural experiment to study the effects of expanding public insurance on insurance coverage, health care use, and health outcomes during preconception, pregnancy, and postpartum. We conducted a systematic review of relevant literature on this topic, analyzing twenty-four studies published between January 2014 and April 2021. We found that the ACA Medicaid expansion increased preconception and postpartum Medicaid coverage with corresponding declines in uninsurance, private insurance coverage, and insurance churn. There was limited evidence that Medicaid expansion increased perinatal health care use or improved infant birth outcomes overall, although some studies reported reduced racial and ethnic disparities in rates of prenatal and postpartum visit attendance, maternal mortality, low birthweight, and preterm births. Stronger data collection on preconception and postpartum outcomes with sufficient sample sizes to stratify by race and ethnicity is needed to assess the full impact of the ACA and emerging Medicaid policy changes, such as the postpartum Medicaid extension.

Effects of parental public health insurance eligibility on parent and child health outcomes

Many states expanded their Medicaid programs to low-income adults under the Affordable Care Act (ACA). These expansions increased Medicaid coverage among low-income parents and their children. Whether these improvements in coverage and healthcare use lead to better health outcomes for parents and their children remains unanswered. We used longitudinal data on a large, nationally representative cohort of elementary-aged children from low-income households from 2010 to 2016. Using a difference-in-differences approach in state Medicaid policy decisions, we estimated the effect of the ACA Medicaid expansions on parent and child health. We found that parents' self-reported health status improved significantly post-expansion in states that expanded Medicaid through the ACA by 4 percentage points (p < 0.05), a 4.7% improvement. We found no significant changes in children's use of routine doctor visits or parents' assessment of their children's health status. We observed modest decreases in children's body mass index (BMI) of about 2% (p < 0.05), especially for girls.

Association of Medicaid Expansion in Arkansas With Postpartum Coverage, Outpatient Care, and Racial Disparities

Importance

Non-Hispanic Black individuals are disproportionally covered by Medicaid during pregnancy and, compared with non-Hispanic White individuals, have higher rates of postpartum coverage loss and mortality. Expanded Medicaid coverage under the Affordable Care Act may have increased continuity of coverage and access to care in the critical postpartum period in expansion states.

Objective

To examine the association of Medicaid expansion in Arkansas with continuous postpartum coverage, postpartum health care use, and change in racial disparities in the study outcomes.

Design Setting and Participants

This cohort study with a difference-in-differences analysis compared persons with Medicaid and commercially financed childbirth, stratified by race, using Arkansas' All-Payer Claims Database for persons with a childbirth between 2013 and 2015. Race and ethnicity from birth certificate data were classified as Hispanic, non-Hispanic Black (hereafter Black), non-Hispanic White (hereafter White), and other (including Asian, Native American or Alaska Native, and Pacific Islander) or unknown race. Data were analyzed between June 2020 and August 2021.

Exposures

Medicaid-paid childbirth after January 1, 2014.

Main Outcomes and Measures

Continuous health insurance coverage and the number of outpatient visits during the first 6 months postpartum.

Results

A total of 60 990 childbirths (mean [SD] age of birthing person, 27 [5.3] years; 67% White, 22% Black, and 7% Hispanic) were included, among which 72.3% were paid for by Medicaid and 27.7% were paid for by a commercial payer. Medicaid expansion in Arkansas was associated with a 27.8 (95% CI, 26.1-29.5) percentage point increase in continuous insurance coverage and an increase in outpatient visits of 0.9 (95% CI, 0.7-1.1) during the first 6 months postpartum, representing relative increases of 54.9% and 75.0%, respectively. Racial disparities in postpartum coverage decreased from 6.3 (95% CI, 3.9-8.7) percentage points before expansion to -2.0 (95% CI, -2.8 to -1.2) percentage points after expansion. However, disparities in outpatient care between Black and White individuals persisted after Medicaid expansion (preexpansion difference, 0.4 [95% CI, 0.2-0.6] visits; postexpansion difference, 0.5 [95% CI, 0.4-0.6] visits).

Conclusions and Relevance

In this cohort study with a difference-in-differences analysis of 60 990 childbirths, Medicaid expansion was associated with higher rates of postpartum coverage and outpatient visits and lower racial and ethnic disparities in postpartum coverage. However, disparities in outpatient visits between Black and White individuals were unchanged. Additional policy approaches are needed to reduce racial and ethnic disparities in postpartum care.

Barriers to Attendance of Prenatal and Well-Child Visits

OBJECTIVE

Prenatal care (PNC) and well child visit (WCV) attendance are associated with improved health outcomes. We aimed to determine if the factors affecting maternal and child attendance are similar or different.

METHODS

We conducted a retrospective case control study at Virginia Commonwealth University Health System. We used the Adequacy of Prenatal Care Utilization Index and the American Academy of Pediatrics recommendations to assess the adequacy of PNC and WCV attendance, respectively. Mothers with less than 50% visit adherence or initiation after 5 months gestation were eligible as cases and those with 80% or more adherence and initiation before 5 months were eligible as controls. Children in the lowest quintile of adherence were eligible as cases and those with 80% or more adherence were eligible as controls. Cases and controls were randomly selected at a 1:2 ratio from the eligible subjects and frequency matched on birth month.

RESULTS

In adjusted analyses, mothers and children who were publicly insured or who were uninsured had higher odds of poor preventive visit attendance. Mothers who experienced intimate partner violence and had more living children were more likely to have poor attendance. Children whose mothers had younger age, greater number of pregnancies and transportation difficulties had poorer attendance.

CONCLUSIONS

While lack of insurance and public insurance remained significantly associated with both poor PNC and WCV attendance, other factors varied between groups. Expanding eligibility requirements and streamlining enrollment and renewal processes may improve two generations of preventive visit attendance.

Effects of medicaid expansion on poverty disparities in health insurance coverage

BACKGROUND

More than 30 states have either expanded Medicaid or are actively considering expansion. The coverage gains from this policy are well documented, however, the impacts of its increasing coverage on poverty disparity are unclear at the national level.

METHOD

American Community Survey (2012-2018) was used to examine the effects of Medicaid expansion on poverty disparity in insurance coverage for nonelderly adults in the United States. Differences-in-differences-in-differences design was used to analyze trends in uninsured rates by poverty levels: (1) < 138 %, (2) 138-400 % and (3) > 400 % federal poverty level (FPL).

RESULTS

Compared with uninsured rates in 2012, uninsured rates in 2018 decreased by 10.75 %, 6.42 %, and 1.11 % for < 138 %, 138-400 %, and > 400 % FPL, respectively. From 2012 to 2018, > 400 % FPL group continuously had the lowest uninsured rate and < 138 % FPL group had the highest uninsured rate. Compared with ≥ 138 % FPL groups, there was a 2.54 % reduction in uninsured risk after Medicaid expansion among < 138 % FPL group in Medicaid expansion states versus control states. After eliminating the impact of the ACA market exchange premium subsidy, 3.18 % decrease was estimated.

CONCLUSION

Poverty disparity in uninsured rates improved with Medicaid expansion. However, < 138 % FPL population are still at a higher risk for being uninsured.

Post-ACA, More Than One-Third Of Women With Prenatal Medicaid Remained Uninsured Before Or After Pregnancy

Medicaid has a long history of serving pregnant women, but many women are not eligible for Medicaid before pregnancy or after sixty days postpartum. We used 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) to describe patterns of perinatal uninsurance and health outcomes of women experiencing uninsurance. We found that 26.8 percent of new mothers with Medicaid-covered prenatal care were uninsured before pregnancy, 21.9 percent became uninsured two to six months postpartum, and 34.5 percent were uninsured in either period, with higher perinatal uninsurance rates in nonexpansion states and for Hispanic women who completed the PRAMS survey in Spanish. Together, our findings indicate that despite recent coverage gains, further policy change is needed to help women maintain health insurance coverage before and after pregnancy and to allow them to address ongoing health issues including obesity and depression.

The effect of Affordable Care Act Medicaid expansion on hospital revenue

Prior research has found that in states which expanded Medicaid under the Affordable Care Act, hospital Medicaid revenue rose sharply, and uncompensated care costs fell sharply, relative to hospitals in nonexpansion states. This suggests that Medicaid expansion may have been a boon for hospital revenue. We conduct a difference-in-differences analysis covering the first four expansion years (2014-2017) and confirm prior results for Medicaid revenue and uncompensated care cost, over this longer period. However, we find that hospitals in expansion states showed no significant relative gains in either total patient revenue or operating margins. Instead, the relative rise in Medicaid revenue was offset by relative declines in commercial insurance revenue. In subsample analyses, we find higher revenue and margins for rural hospitals in expansion states, little change for small urban hospitals, and a revenue decline for large urban hospitals.

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

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. We evaluated whether increased access to health insurance under the Affordable Care Act Medicaid expansions affected ten preconception health indicators, including the prevalence of chronic conditions and health behaviors, birth control use and pregnancy intention, and receipt of preconception health services. By comparing changes in outcomes for low-income women in expansion and nonexpansion states, we document greater preconception health counseling, prepregnancy folic acid intake, and postpartum use of effective birth control methods among low-income women associated with Medicaid expansion. We do not find evidence of changes on the other preconception health indicators examined. Our findings indicate that expanding Medicaid led to detectable improvements on a subset of preconception health measures.

Overturning the ACA's Medicaid Expansion Would Likely Decrease Low-Income, Reproductive-Age Women's Healthcare Spending and Utilization

In late 2020, the Supreme Court began hearing a case challenging the Affordable Care Act (ACA), which led to coverage gains for many low-income, reproductive-age women. To explore potential implications of a full ACA repeal for this population, we examined gains experienced after Medicaid expansion, assuming that such gains may be reversed. Using restricted 2013 to 2014 data from the Medical Expenditure Panel Survey for 1190 women ages 18 to 44 with household incomes below 138% of the federal poverty level, we compared the change in healthcare spending and utilization for women living in expansion states to the change in non-expansion states using a difference-in-differences design. We found that if Medicaid expansion were overturned, Medicaid coverage is likely to decrease, as well as Medicaid spending and prescription drug utilization.