This paper, co-authored by Ashley Fox, is published in the American Journal of Preventive Medicine at https://www.sciencedirect.com/science/article/pii/S0749379726000632

Abstract

Introduction

Extending Pregnancy Medicaid coverage to 12 months postpartum is a key strategy to reduce maternal morbidity and mortality and may be most impactful among states that did not expand Medicaid as part of the Affordable Care Act (ACA). The continuous Medicaid coverage provision enacted at the onset of the COVID-19 pandemic provides a natural experiment to test the impact of postpartum Medicaid extension policies.

Methods

A cross-sectional pre-post design was used to estimate changes in postpartum insurance after the introduction of continuous Medicaid coverage. Using 2016-2023 American Community Survey (ACS) data, non-Hispanic Black and non-Hispanic White respondents aged 19-50 who gave birth in the previous 12 months were included (n=157,016). Postpartum insurance was categorized as Medicaid, private, or uninsured. Linear regression models compared expansion and non-expansion states within Black and White respondents for each year pre- and post-continuous coverage, with 2019 as the reference year. Covariate-adjusted regressions included respondents’ age, employment status, and household income.

Results

Pre-pandemic uninsurance rates among Black women were 16.5% in non-expansion states and 6.4% in expansion states, and among White women they were 11.1% and 5.4%, respectively. Among Black women, uninsurance decreased after continuous coverage in non-expansion states only. For example, in 2023, Black postpartum uninsurance decreased in non-expansion states 5.2 percentage points (pp) more (95%CI= -8.9, -1.5) than in expansion states; this was driven by a 3.9pp larger gain in Medicaid in non-expansion states than expansion states (95%CI= -1.8, 9.6). Among White women, uninsurance decreases in 2021-2023 were also larger in non-expansion states but were driven by gains in private insurance. As a result, Black-White disparities in postpartum uninsurance remained unchanged.

Conclusions

Postpartum uninsurance decreased among Black women in non-expansion states after continuous coverage, but racial inequities persisted.