Elsa Pearson (@epearsonbusph) is a senior policy analyst at Boston University School of Public Health.
Maternal mortality is high in the US, and yet, over 60 percent of pregnancy-related deaths are preventable. (Worth noting, there are data limitations given recent changes to how the US reports maternal mortality.)
Pregnancy-related deaths are nearly evenly split among the prenatal, perinatal, and postnatal (or postpartum) periods, so all phases warrant attention. There are persistent racial disparities as well; the rate of pregnancy-related deaths per 100,000 live births is two to three times higher for black women than for white women. American Indian or Alaska Native women are also at high risk.
Consistent health insurance coverage is critical for adequate access to care that can improve maternal and infant health. And yet, postpartum health insurance coverage in the US has substantial gaps.
Medicaid covers over 40 percent of births nationwide but coverage ends 60 days postpartum, leaving the mother vulnerable should she experience any pregnancy-related complications late in the “fourth trimester” and beyond. The passage of the Affordable Care Act in 2010 offered states the opportunity to expand Medicaid eligibility. Studies show that Medicaid expansion can lead to earlier initiation of prenatal care, better prenatal care, and reduced rates of maternal mortality.
A new study by Sarah Gordon, Benjamin Sommers, Ira Wilson, and Amal Trivedi looked at the impact of Medicaid expansion on postpartum insurance coverage and care utilization. (The researchers are affiliated with the Department of Health Law, Policy, and Management at Boston University School of Public Health, Harvard T. H. Chan School of Public Health, Brown University School of Public Health, Brigham and Women’s Hospital, and the Providence VA Medical Center.)
The researchers sought to determine if Medicaid expansion in Colorado led to an increase in the duration of postpartum Medicaid coverage and/or utilization of outpatient postpartum care. They compared Colorado to Utah which had not yet expanded Medicaid.
The study included 24,528 mothers in Utah and 42,144 mothers in Colorado, 19 years and older, covered by Medicaid between January 2013 and June 2015. During that time, Utah’s Medicaid program covered pregnant women (until 60 days postpartum) below 133 percent of the federal poverty level (FPL) and all adults below 44 percent FPL. Prior to Medicaid expansion, Colorado covered pregnant women (again, until 60 days postpartum) below 185 percent FPL and all adults below 105 percent FPL. In January 2014, the state expanded Medicaid to include all adults below 138 percent FPL. This means that, after 60 days postpartum, low-income mothers would be more likely to be Medicaid eligible in Colorado than in Utah.
To measure the duration of Medicaid coverage during the first six months postpartum, Gordon et al. counted the number of months between the date of delivery and the last day of Medicaid enrollment. To measure postpartum care utilization, the researchers counted the number of outpatient visits that occurred during the first six months postpartum.
Lastly, they assessed whether there were differences in coverage duration and/or care utilization based on maternal morbidity. In other words, did women who experienced severe maternal morbidity —complications such as hemorrhage or sepsis — have different experiences than women who did not? Gordon et al. hypothesized that women who experience severe maternal morbidity would benefit the most from improved postpartum coverage.
After January 2014, mothers living in Colorado retained postpartum Medicaid coverage for 0.90 months more than those in Utah. When stratifying for maternal morbidity, mothers with severe maternal morbidity retained insurance coverage even longer — 1.40 months more — in Colorado than in Utah. The researchers suggest this was due to both a preservation of coverage in Colorado (mothers didn’t gain more coverage with Medicaid expansion, they simply maintained what they already had) and an erosion of coverage in Utah (mothers lost their coverage postpartum).
They also found that mothers in Colorado had 0.52 more outpatient visits in the first four months postpartum than mothers in Utah. When stratifying for maternal morbidity, mothers with severe maternal morbidity used even more postpartum care — 1.25 visits more — in Colorado than in Utah. Unlike insurance coverage, this was likely due to an actual increase in utilization after Medicaid expansion in Colorado as well as a decrease in Utah.
The researchers concluded that Medicaid expansion in Colorado offered new mothers, particularly those who experienced severe maternal morbidity, more stability in postpartum coverage and increased access to outpatient care compared to Utah, which had not yet expanded Medicaid. These findings are relevant to ongoing consideration of expanding postpartum Medicaid coverage in several states, as well as at the federal level. The “fourth trimester” is a vulnerable time in a new mother’s life, and stable insurance coverage and access to high quality care is critical to improving maternal health in the US.