Medicaid Expansion Fills Gaps in Maternal Health Coverage Leading to Healthier Mothers and Babies by Adam Searing and Donna Cohen Ross Key Findings Introduction zz New research shows states that expand Medicaid Disruptions in health coverage are associated with improve the health of women of childbearing age: adverse health consequences.1 This is especially true for increasing access to preventive care, reducing women in their childbearing years, when a pregnancy adverse health outcomes before, during and after means having health coverage is even more important. pregnancies, and reducing maternal mortality rates. The stakes are high as the care a woman receives during zz While more must be done, Medicaid expansion is pregnancy is critical to her own health, as well as to the an important means of addressing persistent racial health of her newborn. In the United States, maternal and disparities in maternal health and maternal mortality. infant mortality is higher than most other industrialized nations,2 lending urgency to strategies to address the zz Better health for women of childbearing age also overall health of women.3 means better health for their infants. States that have expanded Medicaid under the Affordable Care In this paper we review the substantial new research Act saw a 50 percent greater reduction in infant showing the significant improvements in access to mortality than non-expansion states. health coverage for women of childbearing age achieved zz The uninsured rate for women of childbearing through the adoption of the Affordable Care Act’s (ACA) age is nearly twice as high in states that have not Medicaid expansion. Better health coverage is important expanded Medicaid compared to those that have not just for women who are pregnant but also for expanded Medicaid (16 percent v. 9 percent). women well before they become pregnant and well after States with the highest uninsured rates for women childbirth. The American College of Obstetricians and of childbearing age are: Alabama, Alaska, Florida, Gynecologists (ACOG) recommends women have access Georgia, Idaho, Mississippi, Nevada, North Carolina, to continuous health coverage in order to increase Oklahoma, South Carolina, Texas and Wyoming. Ten preventive care, reduce avoidable adverse obstetric and of these twelve states have not expanded Medicaid. gynecologic health outcomes, increase early diagnosis of disease and reduce maternal mortality rates.4 Research also finds that Medicaid expansion has an important role The authors would like to thank the in reducing the significant and persistent racial disparities American College of Obstetricians and Gynecologists and in maternal and infant health. And finally, new studies the March of Dimes for their contributions to this report. show that healthier mothers mean healthier infants— another benefit for states that expand Medicaid. May 2019 CCF.GEORGETOWN.EDU MEDICAID EXPANSION AND MATERNAL HEALTH 1 Pre-ACA Medicaid Expansions Focused on Pregnancy Status Over the past four decades, in response to concerns about that the strong connection between the health of a mother high rates of infant mortality and poor birth outcomes, states and her baby begins well before pregnancy and continues have increased Medicaid eligibility for pregnant women, long past the 60 days of post-partum coverage Medicaid making health care during pregnancy significantly more typically provides.5 This elevates the need for overall good accessible for lower-income women. health throughout a woman’s childbearing years. Innovative efforts such as the University of North Carolina’s 4th Trimester While this has been a positive change for both mothers and Project, in collaboration with groups like the March of Dimes, children, it is only one part of a comprehensive strategy to are highlighting how increasing coverage is a key part of a improve maternal and child health. It has been established comprehensive strategy to improve the health of new mothers.6 The Effect of State Medicaid Expansions Reviews of state data estimate the majority of pregnancy- prenatal care. And postpartum coverage has improved for related deaths are preventable.7 Expanding access to health women, helping them get the care they need following the coverage is a key strategy for addressing this problem. birth of their child. States that have expanded Medicaid also A growing body of research demonstrates the ACA and have decreased the likelihood that eligibility for coverage implementation of state Medicaid expansions have had will fluctuate, resulting in losing and regaining coverage over positive effects on the health of mothers and their infants. a relatively short span of time, a phenomenon known as Recent studies show that state Medicaid expansions have “churning.” Breaks in health coverage can disrupt care and helped to reduce the rates of both maternal deaths and cause existing health conditions to become more serious infant mortality. Women are getting better health coverage and more difficult and expensive to treat.8 before pregnancy, leading to improved prenatal nutrition and Pre-ACA Medicaid Expansions for Pregnant Women and Coverage Churn for Women of Childbearing Age In the late 1980s, prompted by high infant mortality rates, coverage for women of childbearing age. (See Appendix A.) many states expanded Medicaid coverage for pregnant In non-expansion states, the median Medicaid eligibility level women. The state median income eligibility for pregnant for parents is 40 percent FPL or $8,532 per year for a family women rose to 185 percent of the federal poverty level (FPL) of three in 2019. This compares to a minimum parental by 2013 and is now 200 percent FPL.9 Low-income parents eligibility level of 138 percent FPL ($29,435 for a family of could also obtain Medicaid coverage but at a much lower three) in states that have expanded Medicaid.10 And women income level, typically well below 100 percent of FPL. The of childbearing age who do not have children under age ACA’s coverage changes, and particularly its expansion of 19 or are currently not pregnant fare much worse in non- Medicaid to both parents and adults without children in the expansion states—they are simply not eligible for Medicaid home with incomes below 138 percent FPL, have the potential at all unless they have a serious disability. to change this situation dramatically. But the Supreme Court’s decision to make Medicaid expansion optional for states, Such limited coverage for low-income women means coupled with ideological objections to Medicaid expansion, coverage churn is more common in non-expansion states. led to some states rejecting the option. This has resulted in Research consistently shows women of childbearing age significant differences across the country in access to health experience high rates of transition between being covered 2 MEDICAID EXPANSION AND MATERNAL HEALTH CCF.GEORGETOWN.EDU May 2019 by different insurance providers or being covered and then a direct impact on the ability of women of childbearing age to becoming uninsured.11 While Medicaid’s relatively high obtain health coverage. While the ACA reduced the uninsured eligibility levels for pregnant women mean a woman’s rate among women of childbearing age across all states, delivery is often covered, these same lower-income women living in states refusing the Medicaid expansion women are at significant risk of being uninsured in the have generally experienced much smaller reductions and are critical months before pregnancy and after delivery. A more likely to remain uninsured. States with above average recent national study found that half of women who were declines in their uninsured rate for women of childbearing insured by Medicaid for their delivery were uninsured prior age are mainly states that have expanded Medicaid. to pregnancy.12 And of these new mothers, 55 percent States that have not expanded Medicaid generally do experienced another coverage gap in the six months after not cover women of childbearing age who do not have giving birth. The authors also note that “[t]he well-being of a disability if they are not pregnant or are not parents of infants can also be negatively affected by their mothers’ lack dependent children. These states generally have extremely of insurance after delivery. Poor management of maternal low eligibility levels for parents to qualify for Medicaid. For mental health adversely affects a child’s cognitive, behavioral, example, in Texas an income of more than $302 a month and socioemotional development.”13 disqualifies the parents in a family of three from enrolling in Table 1 shows that Medicaid expansion decisions have had Medicaid. See Table 2. Medicaid Expansion Provides Benefits that Confer Two-Generation Advantages ACA Medicaid expansions provide women of childbearing age their state’s full benefit package for adults. These services can benefit their children, as well. For example: zz Maternal Depression Screening and Treatment. Research estimates that more than half (55 percent) of all infants in families with incomes below the poverty level are being raised by mothers with some form of depression.a In addition to the toll depression takes on the mother herself, it also can disrupt the formation of a strong parent-child relationship, which compromises a child’s early brain development, with implications for cognitive, social and emotional health. State Medicaid programs must make depression screening without cost-sharing available to women enrolled under Medicaid expansions, and refer women at risk of perinatal depression to counseling. Many states have adopted the option to allow pediatric care providers to conduct maternal depression screenings as part of the well-child visit and also to deliver “dyadic treatment” to mother and child together.b In Medicaid expansion states, mothers have access to additional treatments they may need, such as more intensive therapy or medication. zz Tobacco Use Cessation. Medicaid enrollees are about twice as likely as the general U.S. population to smoke tobacco: 32 percent of beneficiaries identify themselves as smokers.c The ACA requires that all state Medicaid programs offer comprehensive tobacco cessation benefits without cost-sharing for pregnant women and for populations made newly eligible under Medicaid expansion. Smoking cessation can not only reduce a woman’s risk of cardiovascular and respiratory disease, cancer and other chronic conditions, it also decreases the chances of pregnancy-related complications, including preterm birth, low birth weight, and sudden infant death syndrome. When adults quit smoking, they also reduce the likelihood that their children will suffer from exposure to second-hand smoke, which can trigger more frequent and severe asthma attacks and is associated with ear infections and even tooth decay. a Tracey Veriker, Jennifer Macomber, and Olivia Golden, “Infants of Depressed Mothers Living in Poverty: Opportunities to Identify and Serve,” The Urban Institute. August 2010. b “Maternal Depression Screening and Treatment: A Critical Role for Medicaid in the Care of Mothers and Children,” CMS Informational Bulletin, May 16, 2016. c L. Ku, B. Bruen, S.Steinmetz, and T. Bysshe, “Medicaid Tobacco Cessation: Big Gaps Remain In Efforts To Get Smokers To Quit,” Health Affairs, Vol. 35, No. 1, January 2016. May 2019 CCF.GEORGETOWN.EDU MEDICAID EXPANSION AND MATERNAL HEALTH 3 Table 1. Percentage Point Decline in the Uninsured Rate for Women of Childbearing Age (18-44), 2013-2017 West Virginia New Mexico Kentucky Louisiana** Arkansas California Nevada Washington Montana** Oregon Arizona Alaska** Michigan Florida Rhode Island Indiana** NATIONAL AVERAGE New Hampshire North Carolina Colorado Kansas New Jersey Mississippi South Dakota Ohio Illinois Georgia Alabama Utah South Carolina Iowa Pennsylvania** Medicaid expansion states New York Non-expansion states Idaho Texas Tennessee ** Five states (Alaska, Indiana, Louisiana, Montana, and Oklahoma Pennsylvania) expanded Maryland Medicaid after December 31, Missouri Wisconsin 2014. Expansion states are only Virginia designated as such if enrollment Minnesota began by the start of 2017. Hawaii Delaware Connecticut Nebraska North Dakota Maine Vermont District of Columbia Wyoming Massachusetts 024681012141618 Source: Data is from a Georgetown University Center for Children and Families analysis of the U.S. Census Bureau American Community Survey (ACS) data, 2013 and 2017 single year estimates from the Integrated Public Use Microdata Series (IPUMS). 4 MEDICAID EXPANSION AND MATERNAL HEALTH CCF.GEORGETOWN.EDU May 2019 Table 2. Medicaid Income Eligibility Limit in Non-Expansion States for Adults as a Percentage of the Federal Poverty Level, January 2019 Parent upper eligibility limit Parent upper eligibility limit Childless adult State (in a family of three) – (in a family of three) – eligibility limit percent of FPL monthly dollar amount (for an individual) Alabama 18% $320 0% Florida 32% $569 0% Georgia 35% $622 0% Idaho* 25% $444 0% Kansas 38% $675 0% Mississippi 26% $462 0% Missouri 21% $373 0% Nebraska* 63% $1,120 0% North Carolina 42% $747 0% Oklahoma 42% $747 0% South Carolina 67% $1,191 0% South Dakota 49% $871 0% Tennessee 95% $1,689 0% Texas 17% $302 0% Utah* 60% $1,067 0% Wisconsin 100% $1,778 100% Wyoming 54% $960 0% Source: Based on a national survey conducted by Kaiser Family Foundation with the Georgetown University Center for Children on Families, 2019. See here for more information on the survey and this table. *Idaho and Nebraska voters approved Medicaid expansion but the expansions are not in effect and may be limited. Utah voters also approved a Medicaid expansion but Utah’s legislature passed a law limiting the expansion to only some of those originally eligible and capping enrollment at the discretion of the state. Note: Among reproductive-age women who remained uninsured in 2016, about 20 percent were likely eligible for comprehensive Medicaid or Children’s Health Insurance Program (CHIP) coverage based on their income, indicating that outreach and enrollment efforts could help boost participation.14 May 2019 CCF.GEORGETOWN.EDU MEDICAID EXPANSION AND MATERNAL HEALTH 5 States Rejecting Medicaid Expansion are Missing an Opportunity to Address Stark Racial Disparities in Maternal Health While strategies to increase women’s health coverage Unsurprisingly, nonelderly adults are much more likely to be have had positive effects, especially in states that have uninsured in states that have not expanded Medicaid.17 Recent expanded Medicaid, stark racial disparities with respect data specifically on women of childbearing age are not available, to maternal mortality and maternal health persist. A recent but overall this disparity in uninsured rates is magnified when race commentary in the Journal of the American Medical is taken into account. For example, the uninsured rate among Association noted that “African American women are nonelderly African Americans is 14 percent in states that haven’t nearly three times as likely to die of complications related expanded Medicaid compared to 8 percent in expansion states. to pregnancy and childbirth compared with white women Nonelderly white children and adults (ages 0-64) experience . . . a gap that has not narrowed in decades.”15 The most lower overall rates of uninsurance: 10 percent in states that recent comprehensive study on these disparities in the haven’t expanded Medicaid compared to 6 percent in expansion American Journal of Obstetrics and Gynecology found: states.18 In Southern states, which make up the majority of those that have not expanded Medicaid, African Americans are “[B]lack women had a higher adjusted rate of severe disproportionately affected and experience higher uninsured rates. maternal morbidity than white women. Our results This is due in large part to the fact that the states that have not confirm that the high risk of adverse outcomes faced expanded Medicaid have larger shares of black residents.19 by black women who give birth in comparison with white women in the United States and are similar to While multiple factors contribute to improving maternal health, findings by others.”16 new research is finding Medicaid coverage is a critical piece of the puzzle, especially for addressing racial inequities in access to affordable coverage and care.20 Share of Total Population that is Black by State and Current Medicaid Expansion Status WA MT NH ME ND VT OR MN MA ID SD NY WI RI WY MI CT IA PA NJ NV NE OH MD IL IN DE UT CO WV DC CA KS VA MO KY NC TN AZ NM OK AR SC < 5% (18 states) AL GA MS LA 5%-15% (20 states) TX > 15% (12 states and D.C.) FL No Medicaid expansion AK (17 states) HI Source: “Changes in Health Coverage by Race and Ethnicity Since Implementation of the ACA, 2013-2017,” Kaiser Family Foundation, February 2019. *Idaho and Nebraska voters approved Medicaid expansion but the expansions are not in effect and may be limited. Utah voters also approved a Medicaid expansion but Utah’s legislature passed a law limiting the expansion to only some of those originally eligible and capping enrollment at the discretion of the state. 6 MEDICAID EXPANSION AND MATERNAL HEALTH CCF.GEORGETOWN.EDU May 2019 Medicaid Expansion: Benefits for Women of Childbearing Age When states decide to expand Medicaid, the resulting gains “More recent state expansions in Medicaid under the in coverage provide benefits that promote preventive health ACA have the potential to impact even more women and practices and can protect women and their children from children as they extend eligibility to all low-income women serious health conditions and even death. Better coverage regardless of parental or pregnancy status.”23 is the starting point for better care overall. In addition to the well-known advantages of being insured during pregnancy, 3. Better care before women become pregnant coordination and quality of care during the pre-pregnancy In Ohio, a 2018 study found that after the state’s Medicaid period and during the postpartum period—sometimes called expansion there was almost a 12 percentage-point increase the “4th trimester”—are especially important.21 in Medicaid enrollment for first-time mothers before they became pregnant. This improved access to proper prenatal Several new studies provide insights into the impacts of care in the first 16 weeks after they became pregnant. The Medicaid expansion for women of childbearing age including researchers identified significant increases in the receipt increased health coverage, earlier prenatal care, better overall of all recommended health screens and a nearly 14 care, lower rates of maternal mortality and a reduction in percentage-point increase in receipt of prenatal vitamins infant mortality. for first-time mothers, compared with increases of 5 and 4 percentage points, respectively, for women with previous 1. Better health coverage for reproductive-age pregnancies. Prenatal vitamins typically contain more iron and women folic acid than standard adult multivitamins. They help prevent Overall, the ACA has had a major impact on increasing anemia during pregnancy and neural tube birth defects (such coverage for all women of reproductive age. This is due as spina bifida), which compromise a baby’s brain and spinal not only to Medicaid expansions but also other coverage cord development. While the authors caution the results also changes like the expansion of dependent coverage to young depend on other factors, including some unique to Ohio, the adults up to age 26, the premium tax credit, elimination of benefits for lower-income women in the state are clear after pre-existing condition exclusions, and required coverage of Medicaid expansion.24 maternity care. However, some low-income women are still at risk. Research published in the American Journal of Public 4. Lower rates of maternal mortality Health reported “significant reductions in uninsurance and Findings from a study presented at the AcademyHealth increases in nongroup private insurance and Medicaid among National Health Policy Conference in February 2019 showed reproductive-aged women” in the first three years following the a link between implementation of Medicaid expansion under ACA’s implementation. Across states, the authors identified the the ACA and lower rates of maternal mortality. An analysis of ACA as the cause of a 7.4 percentage-point decrease in the data from 1999 to 2016 from the National Center for Health probability of uninsurance for reproductive age women. Low- Statistics compared maternal mortality rates in Medicaid income women in non-expansion states were identified as expansion states with rates in states that did not expand. The a main group still at risk for lack of coverage.22 study found that Medicaid expansion was associated with lower rates of maternal mortality, reflecting 1.6 fewer maternal 2. Earlier initiation of prenatal care deaths per 100,000 women. The researchers suggest that the The first long-term study examining the effect of pre-ACA reduction in maternal death rates is associated with women Medicaid expansions on women of childbearing age found having increased access to Medicaid prior to pregnancy, multiple positive effects. Medicaid expansions improved which presented the opportunity to address pre-pregnancy coverage prior to pregnancy and led to “earlier initiation risk factors such as obesity, diabetes and heart disease and and improved adequacy of prenatal care among pregnant also to begin prenatal care in a timely manner.25 mothers.” Based on the findings, the author concluded that May 2019 CCF.GEORGETOWN.EDU MEDICAID EXPANSION AND MATERNAL HEALTH 7 5. Reductions in infant mortality was more than 50 percent greater than in non-expansion states. The research also showed that the decline in infant A study released in 2018 examined Medicaid expansions mortality rates linked to Medicaid expansion were greatest under the Affordable Care Act and their effect on the infant among African American infants, which drove the overall mortality rate in the United States. The researchers point out decline and helped to substantially reduce the racial disparity that since Medicaid covers a large proportion of maternal, in infant mortality rates.26 And this improvement was not infant, and child health care, as well as specific services limited to overall infant mortality. Another recently released related to pregnancy, maternity, pediatric care, chronic study examining the effect of state Medicaid expansions on disease management, breastfeeding support, contraception, overall birth outcomes found that while the rates of preterm mental health and substance use disorder screening and birth and low birth weight did not show a change, there were treatment, and other behavioral health services; “Medicaid significant improvements for African American infants relative expansion may be among the most important ways in to white infants. State Medicaid expansion was associated which the ACA could improve maternal and child health with “significant improvements in disparities for black infants indicators, such as the infant mortality rate.” Their analysis relative to white infants for the four outcomes studied, found that the infant mortality rate declined in both Medicaid including preterm birth, very preterm birth, low birth weight, expansion and non-expansion states between 2010 and and very low birth weight.”27 2016, however, the decline in Medicaid expansion states Conclusion Medicaid expansion under the Affordable Care Act offers years, has reduced the rate of women of childbearing age affordable, comprehensive health coverage to women who are uninsured, and has improved health outcomes. who would likely otherwise go without access to needed Medicaid expansion has also played a role in reducing rates care. Most states have longstanding, generous Medicaid of maternal death, decreasing infant mortality rates, and coverage for pregnant women, however, the pre-pregnancy improving the potential for optimal birth outcomes that can coverage churn and post-partum (or “4th trimester”) increase the prospects for a healthy childhood. Finally, it is coverage gaps leave women without a full continuum of clear if the remaining non-expansion states want to address care. Prior to pregnancy, this can mean a significant missed significant racial disparities in maternal and infant health, opportunity to attend to health issues that pose high risks expanding Medicaid is a critical first step. during pregnancy for mother and child. Similarly, a sudden plunge into uninsured status after the Medicaid post-partum Additional research could further illuminate the value of period of 60 days can force women to abandon medication Medicaid expansion for women and their children. Many or other ongoing treatment they may need. And despite of the benefits Medicaid provides—smoking cessation improved coverage during pregnancy, troubling racial treatment, treatment for substance use disorders, maternal maternal and infant health disparities persist, especially in depression screening and treatment, oral healthcare and Medicaid non-expansion states. other benefits—are likely to have positive two-generation impacts on women and their children. Recent studies show that Medicaid expansion has increased coverage rates for women during the childbearing 8 MEDICAID EXPANSION AND MATERNAL HEALTH CCF.GEORGETOWN.EDU May 2019 Appendix A. Medicaid Income Eligibility Limit for Adults as a Percent of the FPL, January 2019 Parent upper eligibility limit (in a Parent upper eligibility limit (in a family Childless adult eligibility State family of three) – percent of FPL of three) – monthly dollar amount limit (for an individual) Alabama 18% $320 0% Alaska 138% $3,066 138% Arizona 138% $2,453 138% Arkansas 138% $2,453 138% California 138% $2,453 138% Colorado 138% $2,453 138% Connecticut 155% $2,755 138% Delaware 138% $2,453 138% District of Columbia 221% $3,928 215% Florida 32% $569 0% Georgia 35% $622 0% Hawaii 138% $2,822 138% Idaho* 25% $444 0% Illinois 138% $2,453 138% Indiana 139% $2,471 139% Iowa 138% $2,453 138% Kansas 38% $675 0% Kentucky 138% $2,453 138% Louisiana 138% $2,453 138% Maine** 138% $2,453 138% Maryland 138% $2,453 138% Massachusetts 138% $2,453 138% Michigan 138% $2,453 138% Minnesota 138% $2,453 138% Mississippi 26% $462 0% Missouri 21% $373 0% Montana 138% $2,453 138% Nebraska* 63% $1,120 0% Nevada 138% $2,453 138% New Hampshire 138% $2,453 138% New Jersey 138% $2,453 138% New Mexico 138% $2,453 138% New York 138% $2,453 138% North Carolina 42% $747 0% North Dakota 138% $2,453 138% Ohio 138% $2,453 138% Oklahoma 42% $747 0% Oregon 138% $2,453 138% Pennsylvania 138% $2,453 138% Rhode Island 138% $2,453 138% South Carolina 67% $1,191 0% South Dakota 49% $871 0% Tennessee 95% $1,689 0% Texas 17% $302 0% Utah* 60% $1,067 0% Vermont 138% $2,453 138% Virginia** 138% $2,453 138% Washington 138% $2,453 138% West Virginia 138% $2,453 138% Wisconsin 100% $1,778 100% Wyoming 54% $960 0% Non-expansion states Source: Based on a national survey conducted by Kaiser Family Foundation with the Georgetown University Center for Children on Families, 2019. See here and here for more information on the survey and this table. * Idaho and Nebraska voters approved Medicaid expansions but the expansions are not in effect and may be limited. ** Medicaid expansions in Maine and Virginia did not go into effect until 2019. May 2019 CCF.GEORGETOWN.EDU MEDICAID EXPANSION AND MATERNAL HEALTH 9 Appendix B. Uninsured Rates by State for Women of Child-Bearing Age (18-44), Comparing Rates for 2013 and 2017 Uninsured Percent 2013 for Uninsured Percent 2017 for Percentage Point Change Region Women Ages 18-44 Women Ages 18-44 2013-2017 US Total 21.0 12.3 -8.7 Alabama 23.0 15.6 -7.4 Alaska 25.5 15.3 -10.2 Arizona 24.2 13.4 -10.8 Arkansas 26.3 11.4 -14.9 California 23.4 9.3 -14.1 Colorado 18.6 10.2 -8.4 Connecticut 12.1 7.5 -4.6 Delaware 12.7 8.1 -4.6 District of Columbia 5.5 3.0 -2.5 Florida 29.0 19 -10.0 Georgia 27.5 20.1 -7.4 Hawaii 9.8 5.2 -4.6 Idaho 24.4 17.6 -6.8 Illinois 17.2 9.7 -7.5 Indiana 21.0 11.7 -9.3 Iowa 12.7 5.8 -6.9 Kansas 20.2 12.0 -8.2 Kentucky 24.0 7.4 -16.6 Louisiana 25.9 10.8 -15.1 Maine 15.8 11.8 -4.0 Maryland 13.9 8.1 -5.8 Massachusetts 4.6 3.3 -1.3 Michigan 16.4 6.4 -10.0 Minnesota 10.8 5.9 -4.9 Mississippi 26.2 18.5 -7.7 Missouri 19.6 13.9 -5.7 Montana 23.7 12.0 -11.7 Nebraska 16.8 12.5 -4.3 Nevada 29.0 15.8 -13.2 New Hampshire 16.5 7.9 -8.6 New Jersey 19.7 11.6 -8.1 New Mexico 29.8 13.1 -16.7 New York 14.2 7.4 -6.8 North Carolina 24.1 15.7 -8.4 North Dakota 14.4 10.2 -4.2 Ohio 15.1 7.6 -7.5 Oklahoma 27.2 21.4 -5.8 Oregon 20.8 9.3 -11.5 Pennsylvania 13.9 7.1 -6.8 Rhode Island 15.8 6.0 -9.8 South Carolina 23.9 16.8 -7.1 South Dakota 19.8 12.3 -7.5 Tennessee 18.9 12.2 -6.7 Texas 32.2 25.5 -6.7 Utah 18.3 11.2 -7.1 Vermont 8.0 5.4 -2.6 Virginia 17.4 12.4 -5.0 Washington 21.4 8.4 -13.0 West Virginia 24.6 7.9 -16.7 Wisconsin 11.8 6.8 -5.0 Wyoming 19.4 17.5 -1.9 Source: Data is from a Georgetown University Center for Children and Families analysis of the U.S. Census Bureau American Community Survey (ACS) data, 2013 and 2017 single year estimates from the Integrated Public Use Microdata Series (IPUMS). 10 MEDICAID EXPANSION AND MATERNAL HEALTH CCF.GEORGETOWN.EDU May 2019 Endnotes 2019-findings-from-a-50-state-survey. 1 B.D. Sommers et al., “Insurance Churning Rates For Low- 11 D. D’Angelo et al., “Patterns of Health Insurance Coverage Income Adults Under Health Reform: Lower Than Expected But Around the Time of Pregnancy Among Women with Live-Born Still Harmful For Many,” Health Affairs 35, no. 10 (October 2016), Infants—Pregnancy Risk Assessment Monitoring System, 29 available at https://doi.org/10.1377/hlthaff.2016.0455. States, 2009,” Morbidity and Mortality Weekly Report 64, no. 2 M.F. MacDorman et al., “International Comparisons of Infant 4 (June 19, 2015): 1-19, available at https://www.jstor.org/ Mortality and Related Factors: United States and Europe, 2010,” stable/24806292. National Vital Statistics Reports 63, no. 5, (September 2014), J. Daw et al., “Women In The United States Experience High 12 available at https://www.cdc.gov/nchs/data/nvsr/nvsr63/nvsr63_05. Rates Of Coverage ‘Churn’ In Months Before And After Childbirth,” pdf. Health Affairs 36 no. 4, (April 2017): 598-606. 3 M.F. MacDorman et al., “Is the United States Maternal Mortality 13 Ibid, page 602. Rate Increasing? Disentangling trends from measurement issues,” Obstetrics & Gynecology, 128 vol. 3 (September 2016): 14 S. McMorrow et al., “Health Insurance Coverage for Women of 447–455, available at https://www.ncbi.nlm.nih.gov/pmc/articles/ Reproductive Age, 2013” (Washington: Urban Institute, December PMC5001799/. 2018), available at https://www.urban.org/sites/default/files/ publication/99534/12.18.18_health_insurance_coverage_for_ 4 American College of Obstetricians and Gynecologists, “Benefits women_of_reproductive_age_2013-16_1.pdf. to Women of Medicaid Expansion Through the Affordable Care Act” (Washington: American College of Obstetricians and Gynecologists, 15 M.C. Lu, “Viewpoint: Reducing Maternal Mortality in the United January 2013), available at https://www.acog.org/Clinical- States,” Journal of the American Medical Association 320 no. 12 Guidance-and-Publications/Committee-Opinions/Committee- (September 5, 2018):1237-1238, available at https://jamanetwork. on-Health-Care-for-Underserved-Women/Benefits-to-Women-of- com/journals/jama/article-abstract/2702413#jvp180101r1. Medicaid-Expansion-Affordable-Care-Act. 16 E.A. Howell et al., “Black-White Differences in Severe Maternal 5 S. McMorrow and G. Kenney, “Despite Progress Under The ACA, Morbidity and Site of Care,” American Journal of Obstetrics and Many New Mothers Lack Insurance Coverage,” (Washington: Gynecology 214, no. 1 (August 15, 2015), available at https://www. Health Affairs Blog, September 2018), available at https://www. ncbi.nlm.nih.gov/pmc/articles/PMC4698019/. healthaffairs.org/do/10.1377/hblog20180917.317923/full/. 17 Kaiser Family Foundation, “Health Coverage & Uninsured” 6 “Fourth Trimester Project,” University of North Carolina School of (Washington: Kaiser Family Foundation), available at https://www. Medicine: Center for Maternal and Infant Health, available at https:// kff.org/state-category/health-coverage-uninsured/nonelderly- www.mombaby.org/4th-trimester-project/. uninsured/. 7 “Report from Nine Maternal Mortality Review Committees” 18 S. Artiga, K. Orgera, and A. Damico, “Changes in Health (Building U.S. Capacity to Review and Prevent Maternal Deaths, Coverage by Race and Ethnicity since Implementation of the ACA, 2018), available at http://reviewtoaction.org/Report_from_Nine_ 2013-2017” (Washington: Kaiser Family Foundation, February MMRCs. 2019), available at https://www.kff.org/disparities-policy/issue- brief/changes-in-health-coverage-by-race-and-ethnicity-since- 8 A. Frakt and A. Carroll, “The consequences of health insurance implementation-of-the-aca-2013-2017/. coverage gaps” (Washington: Academy Health, January 2014), available at https://www.academyhealth.org/blog/2014-01/ 19 Ibid. consequences-health-insurance-coverage-gaps. 20 National Partnership for Women and Families, “Black Women’s 9 Kaiser Family Foundation, “Where Are States Today? Medicaid Maternal Health: A Multifaceted Approach to Addressing and CHIP Eligibility Levels for Children, Pregnant Women, and Persistent and Dire Health Disparities” (Washington: Partnership Adults” (Washington: Kaiser Family Foundation, Mar 31, 2019), for Women and Families, April 2018), available at http://www. available at https://www.kff.org/medicaid/fact-sheet/where-are- nationalpartnership.org/our-work/resources/health-care/maternity/ states-today-medicaid-and-chip/. black-womens-maternal-health-issue-brief.pdf. 10 T. Brooks, L. Roygardner, and S. Artiga, “Medicaid and CHIP 21 S. Verbiest et al., “Advancing preconception health in the United Eligibility, Enrollment, and Cost Sharing Policies as of January 2019: States: strategies for change,” Upsala Journal of Medical Sciences, Findings from a 50-State Survey” (Washington: Center on Children 121 no. 4 (September 2016):222-226. and Families and the Kaiser Family Foundation, March 2019), 22 J.R. Daw and B.D. Sommers, “The Affordable Care Act and available at https://www.kff.org/medicaid/report/medicaid-and- Access to Care for Reproductive-Aged and Pregnant Women in the chip-eligibility-enrollment-and-cost-sharing-policies-as-of-january- May 2019 CCF.GEORGETOWN.EDU MEDICAID EXPANSION AND MATERNAL HEALTH 11 United States, 2010-2016,” American Journal of Public Health 109 Conference, (presentation, Washington, February 4, 2019), available (2019):565-571. at https://academyhealth.confex.com/academyhealth/2019nhpc/ meetingapp.cgi/Paper/29402. See also: Jaime Rosenberg, 23 L.R. Wherry, “State Medicaid Expansions for Parents Led to “Medicaid Expansion Linked to Lower Maternal Mortality Rates,” Increased Coverage and Prenatal Care Utilization among Pregnant AJMC Managed Markets News, February 6, 2019, available Mothers,” Health Services Research (December 2017), available at at https://www.ajmc.com/conferences/academyhealth-2019/ https://www.ncbi.nlm.nih.gov/pubmed/29282721. medicaid-expansion-linked-to-lower-maternal-mortality-rates26 24 E.K. Adams et al., “Prepregnancy Insurance and Timely Prenatal C.B. Bhatt and C.M. Beck-Sagué, “Medicaid Expansion and Infant Care for Medicaid Births: Before and After the Affordable Care Act Mortality in the United States,” American Journal of Public Health in Ohio,” Journal of Women’s Health (August 2018). 108 no. 4 (April 2018):565-567, available at https://www.ncbi.nlm. 25 Erica Eliason, “Adoption of Medicaid Expansion under the nih.gov/pmc/articles/PMC5844390/. Affordable Care Act is Associated with Lower Rates of Maternal 27 H.Bauchner and K.J. Maddox, “Medicaid Expansion and Birth Mortality,” Academy Health 2019 National Health Policy Outcomes” Journal of the American Medical Association 321 no. 16 (April 2019), available at https://jamanetwork.com/journals/jama/ fullarticle/2731153. Written by Adam Searing and Donna Cohen Ross. The authors would like to thank Joan Alker and Catherine Hope for their contributions to this brief. Design and layout provided by Nancy Magill. The Georgetown University Center for Children and Families (CCF) is an independent, nonpartisan policy and research center founded in 2005 with a mission to expand and improve high-quality, affordable health coverage for America’s children and families. CCF is based in the McCourt School of Public Policy’s Health Policy Institute. Georgetown University Center for Children and Families ccf.georgetown.edu/blog/ McCourt School of Public Policy Box 571444 facebook.com/georgetownccf 3300 Whitehaven Street, NW, Suite 5000 Washington, DC 20057-1485 twitter.com/georgetownccf Phone: (202) 687-0880 Email: childhealth@georgetown.edu 12 MEDICAID EXPANSION AND MATERNAL HEALTH CCF.GEORGETOWN.EDU May 2019