Medicaid expansions, preconception insurance, and unintended pregnancy among new parents

Abstract

Objective: To assess the relationship between recent changes in Medicaid eligibility and preconception insurance coverage, pregnancy intention, health care use, and risk factors for poor birth outcomes among first-time parents.

Data source: This study used individual-level data from the national Pregnancy Risk Assessment Monitoring System (2006-2017), which surveys individuals who recently gave birth in the United States on their experiences before, during, and after pregnancy.

Study design: Outcomes included preconception insurance status, pregnancy intention, stress from bills, early prenatal care, and diagnoses of high blood pressure and diabetes. Outcomes were regressed on an index measuring Medicaid generosity, which captures the fraction of female-identifying individuals who would be eligible for Medicaid based on state income eligibility thresholds, in each state and year.

Data collection/extraction methods: The sample included all individuals aged 20-44 with a first live birth in 2009-2017.

Principal findings: Among all first-time parents, a 10-percentage point (ppt) increase in Medicaid generosity was associated with a 0.7 ppt increase (P = 0.017) in any insurance coverage and a 1.5 ppt increase (P < 0.001) in Medicaid coverage in the month before pregnancy. We also observed significant increases in insurance coverage and early prenatal care and declines in stress from bills and unintended pregnancies among individuals with a high-school degree or less.

Conclusions: Increasing Medicaid generosity for childless adults has the potential to improve insurance coverage in the critical period before pregnancy and help improve maternal outcomes among first-time parents.

Keywords: Medicaid; maternal and perinatal care and outcomes; patient protection and affordable care act; preconception care; pregnancy; prenatal care; state health policies; unplanned.

FIGURE 1

Average generosity index for all states in PRAMS. Note: Figure includes the Medicaid generosity index for first‐time mothers for all 43 states included in Pregnancy Risk Assessment Monitoring Survey (PRAMS) data at any time during the study period (2009‐2017). Individual states are shown in light gray and the average across all 43 PRAMS states is shown in dark gray

FIGURE 2

Regression results for first‐time mothers. Note: Figure includes regression coefficient and 95% confidence interval from the regressions estimated in Table 2. For results for week of initiation of prenatal care in 1st trimester, see Table 2. Regressions were estimated among all first‐time parents and first‐time parents with a high‐school degree or less

FIGURE 3

Week of first prenatal care visit in first trimester among individuals with a high‐school degree or less. Note: Figure includes the cumulative percent of first‐time parents with a high‐school degree or less who reported initiating prenatal care by week of pregnancy. Expansion states include those states that covered childless adults by 2014 or earlier. Nonexpansion states include states that did not provide any coverage for childless adults during the study period. Pre‐ACA includes births with a preconception period (one year prior to date of delivery) prior to 2014 and post‐ACA includes births with a preconception period after 2014