How does the ACA expansion affect Medicaid coverage before and during pregnancy?

How does the ACA expansion affect Medicaid coverage before and during pregnancy?

Medicaid is a major source of coverage for pregnant women, funding about four in ten births nationwide and a majority in some states. A recent report on maternal health found that more than 80% of pregnancy-related deaths were preventable and recommended broader access to health insurance, which can improve prenatal care initiation and postpartum follow-up. pregnancy. A previous KFF analysis found that those enrolled after childbirth in Medicaid expansion states had greater continuity of Medicaid coverage in the year after childbirth, compared to those enrolled in non-expansion states. However, the analysis did not examine coverage in the months before delivery. Coverage before and throughout pregnancy can support pre-pregnancy health care and early prenatal care, including many services and tests provided during the first trimester, which can lead to healthier pregnancies and help to reduce the risk of complications. In this brief, we examine whether Medicaid expansion also helps women enroll earlier in the months leading up to pregnancy and childbirth using Medicaid claim data for women with live births in 2019. .

Women in expanding states are more than twice as likely to be enrolled in Medicaid before becoming pregnant as women in non-expanding states (Figure 1). Most (59%) of registrants in expanding states with a live birth were enrolled before pregnancy (at least 11 months before delivery), while only 26% of registrants in non-expanding states were enrolled before pregnancy. Four in ten (40%) enrollees with a live birth in non-expanding states enrolled after they became pregnant or soon after (7-10 months before giving birth). Generally, the income limits for pregnant women to qualify for Medicaid coverage are higher than the limits for other adults, allowing many women to become eligible for Medicaid once they become pregnant. The difference in income levels between pregnant adults and other adults is particularly large in non-expanding states (Appendix Table 1), which helps explain why a smaller proportion of women in these states are enrolled in Medicaid prior to the expansion. early pregnancy. Other research found that most women newly enrolled in Medicaid during pregnancy were uninsured before enrolling, and the rate of uninsured women who receive pregnancy-related Medicaid coverage is higher. in non-expanding states.

Women in non-expanding states are more likely to enroll later in their pregnancies than women in expanding states. About one-third (34%) of pregnant women in non-expanding states enrolled in Medicaid within six months of giving birth, around the second trimester or later in their pregnancy, compared to 22% of women in states of expansion. Smaller proportions of women enrolling in Medicaid during the month of childbirth might have been uninsured at the time of childbirth, but were found to be eligible while in hospital.

Our analysis of antenatal coverage in Medicaid is based on KFF searchwho together conclude that Medicaid expansion promotes continuity of coverage during the prenatal and postpartum periods. Other research also reveals that the expansion helped improve a number of reproductive health outcomes. Going forward, Medicaid expansion could be a key issue in several state elections. In the 12 states that did not enact Medicaid expansion starting in 2022, all but two (North Carolina and Mississippi) have gubernatorial elections coming up in November 2022. Additionally, residents of Dakota of the South will vote on a ballot measure to enact expansion of Medicaid through a constitutional amendment. If passed, the amendment would direct the state to implement Medicaid expansion by July 1, 2023. In North Carolina, state lawmakers can resume discussions on expansion of Medicaid, which were passed in separate bills in the two state legislatures but were not included in the final budget bill for fiscal year 2023. States that are recently implementing Medicaid expansion will receive a temporary tax incentive under the American Rescue Plan Act through improved federal matching on most Medicaid spending. The outcome of the recent court ruling overturning Roe vs. Wade highlighted the importance of health coverage for women and children, especially those with low incomes.



Data source and sample selection

Our analysis uses the Transformed Medicaid Statistical Information System (T-MSIS) Research Identifiable Files (RIF) Analytical Files (TAF), 2018 – 2019, Version 1. (DE) Core File and DE Date File. We used BENE_ID to bind files when available, and when BENE_ID was missing, we used MSIS_ID to bind files (see the TMSIS User Guide for more information on bind variables).

To identify Medicaid enrollees with a live birth in 2019, we use the live birth reference codes provided by Calkins et al. in their technical specification for “Maternal and Infant Health (MIH): Identifying Pregnant and Postpartum Beneficiaries in Administrative Data”, available on the CMS website. After reporting patients with a live birth in 2019 in claim records, we merged the claim record with eligibility records and excluded those enrolled through a medically needy eligibility pathway or through an insurance program separate children’s disease (SCHIP) during the month of childbirth. Finally, we measured the duration of continuous enrollment of women until delivery. If enrollees had a coverage gap of 27 days or less (less than a month), we considered that person to be permanently enrolled prior to the prenatal coverage gap. If an enrollee had a coverage gap during the prenatal period of 28 days or more, we only included the last enrollment period following the gap and leading up to childbirth. However, we expect that very few pregnant women will have gaps in coverage because the federal government requires pregnant enrollees to have continued eligibility from the month of the Medicaid application until at least 60 days after pregnancy. ‘childbirth.

State exclusion criteria

We use data from 39 states in our analysis. We exclude 12 states (AL, DC, FL, KS, KY, NC, NE, NM, OK, RI, TN, and WY) due to missing or inconsistent data based on state-level information available in the Atlas DQ as well as our own analysis of CDC Wonder Natality files. We used several measures from the Atlas DQ to assess the quality of state data, shown in Appendix Table 2. We further excluded states whose final sample in this analysis had a difference of 20% or more in the number of births covered by Medicaid in the CDC. Wonder birth files. In total, our final sample included 1,259,397 deduplicated enrollees with a live birth, while CDC Wonder reported 1,254,767 Medicaid-covered newborns (a +0.4% difference from CDC Wonder).

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