Medicaid Expansion Increased Preconception Health Counseling, Folic Acid Intake, And Postpartum Contraception


Maternal and infant mortality is higher in the United States than in most developed countries,1,2 particularly among women in low-income communities.3,4 Although national policies designed to improve pregnancy and birth outcomes have historically targeted disadvantaged women during pregnancy, there is growing recognition that the period before pregnancy also shapes the subsequent health of expectant mothers and their children.58 Maternal risk factors associated with poor pregnancy outcomes often arise years before conception, making intervention during pregnancy “too little, too late.”5 In addition, the period after pregnancy provides an important opportunity for continued care related to maternal health and the receipt of family planning services, which may affect the outcomes for subsequent pregnancies.9

Expanding health insurance coverage has the potential to increase women’s access to affordable health care during nonpregnancy periods. The Affordable Care Act (ACA) has drastically changed the health policy landscape by introducing new coverage options for low-income women. Although all states provided Medicaid coverage to low-income women for pregnancy-related services during pregnancy and up to sixty days postpartum before the ACA, eligibility criteria for women before and after pregnancy were far more restrictive. Women without children did not qualify for Medicaid in most states, and income eligibility thresholds were low for women with children (the median state threshold for eligibility for working parents in 2013 was 61 percent of the federal poverty level).10 This contributed to gaps in coverage and access to health services both before and after pregnancy.11,12

Under the ACA, thirty-six states and Washington, D.C., had implemented Medicaid expansions for adults with incomes up to 138 percent of the federal poverty level as of October 2020,13 providing a new eligibility pathway for women to obtain Medicaid coverage when they are not pregnant. This change led to an immediate and large increase in insurance coverage among low-income women of reproductive age in expansion states when compared with nonexpansion states.14 In general, women without children experienced the largest changes in insurance coverage after the ACA Medicaid expansions, although women with children in states with low parental eligibility thresholds also experienced large increases in insurance coverage. The Medicaid expansions and other ACA coverage expansions improved access to care for reproductive-age women, including increased access to physicians and fewer cost barriers to receiving care.1416 These changes may translate into improved maternal and infant health if they support the prevention and treatment of important medical and behavioral risk factors during nonpregnancy periods.

This article evaluates the impact of the ACA Medicaid expansions on women’s health before pregnancy, using ten key indicators of preconception health. These indicators measure risky behaviors and the prevalence of chronic health conditions among women of reproductive age who may become pregnant, monitor birth control use and pregnancy intention status, and track the use of essential preconception health services among women who become pregnant. Nine of these indicators were identified as prioritized measures for monitoring preconception health status by the National Preconception Health and Health Care Initiative; the last was a core state preconception health indicator identified by the Centers for Disease Control and Prevention (CDC).17,18

The impact of Medicaid eligibility expansions on preconception health is difficult to predict and could change over time. On the one hand, Medicaid expansions could increase diagnosis of chronic disease by increasing access to care,19,20 leading to an uptick in measured health risks before pregnancy. On the other hand, improved access to tools to identify and manage chronic disease risk factors could influence health behaviors and reduce the true prevalence of health risks in the long run. A recent analysis examined the health of women of reproductive age and found no changes in chronic conditions, smoking cessation, or body mass index associated with the ACA Medicaid expansions, using data through 2016.16 The authors did find, however, improved self-reported health and decreased binge drinking associated with expanded Medicaid eligibility.

We extended this line of inquiry by using more recent data (through 2018) and examining changes in a prioritized list of preconception health indicators.17,18 In addition to measures of chronic conditions and health behaviors among women of reproductive age, we examined changes in the use of essential preconception health services among women who become pregnant. These include preconception health counseling and daily folic acid intake, which is recommended by the US Preventive Services Task Force because of the large effect of early pregnancy folic acid consumption on the prevention of neural tube defects among newborns.21,22 We also examined whether there were changes in pregnancy intention, which may result from increased access to family planning services, and postpartum use of effective methods of contraception. Contraception use after pregnancy may reduce future unintended pregnancies or short interpregnancy intervals, which are associated with increased risk for adverse maternal and infant outcomes.23,24 For this reason, the postpartum period can represent an important component of the preconception period for subsequent pregnancies.

We also examined changes in insurance status during the prepregnancy and postpartum periods, which are the hypothesized pathways for Medicaid eligibility expansions to improve preconception health. Expanded eligibility for health insurance before and after pregnancy may promote more continuous coverage and increase the receipt of recommended health services, including family planning, preventive care, and treatment for chronic health conditions. Previous studies have documented increased or more stable Medicaid coverage after the ACA Medicaid expansions during both the prepregnancy and postpartum periods.2527 We present these estimates for our specific study sample to help with interpretation of our findings.

Study Data And Methods

Data And Sample

Because more than one-third of births are unintended at the time of conception,28 preconception health indicators measure health not only among women who become pregnant but also among all nonpregnant women of reproductive age. In our analyses we used data from two distinct CDC surveillance systems that track each of these populations.

First, to measure changes in preconception health among nonpregnant women of reproductive age, we used the 2011–18 years of the Behavioral Risk Factor Surveillance System (BRFSS), a survey of noninstitutionalized adults in all fifty states and Washington, D.C.29 The BRFSS collects detailed information on respondents’ health risk behaviors and chronic health conditions. We selected 2011 as the start of the study period because of significant changes made in the sampling scheme in that year.29 Using information on household size and income, we identified women with household incomes at or below 138 percent of the federal poverty level who would be eligible for the Medicaid expansions. Household size was calculated as the sum of the number of children and adults per household. In the BRFSS, income is reported in discrete bins; we used the midpoint of each bin to assign a precise income level to the household.

Second, we examined changes in preconception health among women with a recent live birth using the 2012–17 years of the Pregnancy Risk Assessment Monitoring System (PRAMS). PRAMS collects information on women’s experiences before, during, and after pregnancy, using interviews starting two to four months after delivery. State participation is optional, and only states meeting a response-rate threshold are included in annual data releases. Our analysis used information for states with data available for the entire study period, yielding a sample of thirteen states (eight expansion and five nonexpansion states; see online appendix exhibit C).30 To restrict the sample to women with household incomes at or below 138 percent of the federal poverty level, we used information on household income and size during the twelve months before birth. Income is reported by category, and we assigned household income using the midpoint of the category, as in the BRFSS.

Outcomes

Our primary outcomes of interest were ten indicators of preconception health constructed using data available in the BRFSS and PRAMS. The indicators in the BRFSS measured the prevalence of health conditions (ever diagnosed with depression, diabetes, or hypertension) and health behaviors (current smoking, normal weight, and recommended physical activity) among nonpregnant women of reproductive age. Two of these measures, hypertension and recommended physical activity, were available for only a subset of years. Indicators in PRAMS measured preconception health among women with a recent live birth. These indicators included receipt of preconception health counseling during the twelve months before pregnancy; daily folic acid intake; whether the pregnancy was unwanted; and postpartum use of an effective method of contraception such as sterilization or an implant, intrauterine device, injectable, pill, patch, or vaginal ring. Each of these measures in PRAMS refers to the preconception or postpartum period for the pregnancy that resulted in a recent live birth.

Secondary outcomes of interest were also constructed to examine changes in insurance coverage during the month before pregnancy (prepregnancy period) and at the time of the postpregnancy interview (postpartum period).

Appendix exhibits A and B contain additional details on outcome definitions and availability.30

Study Design

The analyses used a difference-in-differences research design to estimate the effects of the ACA Medicaid eligibility expansions. Under this design, changes in outcomes before and after implementation of ACA Medicaid expansions (first difference) were compared in expansion versus nonexpansion states (second difference). This comparison of outcomes in states with versus without implementation of Medicaid expansions allowed us to control for the role of concurrent national changes affecting both groups of states, such as national expansions in access to private insurance coverage in 2014. The underlying assumption is that outcomes would have evolved similarly in the two groups of states in the absence of the ACA Medicaid expansions.

Expansion states were states that implemented the ACA Medicaid expansion at any point during the study period. The postexpansion period in each state began on the date the expansion was implemented in that state. In total, twenty-seven states expanded Medicaid eligibility in 2014, the first year of the policy, and an additional five states expanded Medicaid eligibility over the course of 2015–18. We excluded four states (Delaware, Massachusetts, New York, and Vermont) and Washington, D.C., because of the enactment of similar Medicaid eligibility expansions before the ACA. We also excluded Wisconsin, which implemented an alternative Medicaid expansion for adults earning up to 100 percent of the federal poverty level in 2014.13

Statistical Analysis

To identify the effects of the ACA Medicaid eligibility expansions, we estimated a linear probability model for each outcome in which the main predictor was an indicator of whether the respondent’s state of residence had expanded Medicaid. In analyses with the BRFSS, expansion status was measured quarterly, using available information on the year and quarter of the interview. In PRAMS, information is available on the year of the child’s birth only. Therefore, the period of exposure to the Medicaid expansions for all outcomes related to the preconception period was the calendar year before birth. For postpartum outcomes, the year of birth was the relevant exposure period. A state was considered to have expanded Medicaid during a given year if implementation occurred before July of that year (see appendix exhibit C).30

All regressions included state and time indicator variables to control for time-invariant differences across states and secular trends that were unrelated to the ACA Medicaid eligibility expansions. Regressions controlled for respondent age, race/ethnicity, marital status, education level, and the number of children in the household. Regressions also controlled for the annual state unemployment rate—a measure of local economic conditions that could influence poverty and access to employment-based insurance. Analyses of outcomes among women with a recent birth using the PRAMS data additionally controlled for state policies relevant to fertility that changed during our study period, including the maximum welfare benefit for a family of three, an indicator for state mandates for private health insurance coverage of contraceptives, and whether states had Medicaid family planning waivers.

All regressions were weighted using the relevant survey weights. Heteroskedasticity-robust standard errors were clustered by state to account for within-state correlation of the error terms.31 In the analyses with PRAMS data, because of the smaller number of states, we used a wild cluster bootstrap procedure to estimate the confidence intervals and p values.32 In all analyses, a significance level of 0.05 was used to determine statistical significance. Appendix exhibit D contains additional details on the models and control variables.30

Sensitivity Analyses

We conducted additional analyses to assess the validity of our findings. The assumption underlying the research design is that in the absence of Medicaid expansion, outcomes would have evolved similarly for the study population in expansion and nonexpansion states (that is, the “parallel trends” assumption). To examine whether there were differential trends in outcomes by expansion status before the policy change, we estimated event study models—that is, models that measured the adjusted differences in outcomes between expansion and nonexpansion states every year before the Medicaid eligibility expansions—and tested for changes in these differences over time. We tested for the joint significance of the preexpansion coefficients in this model. In an additional check, we tested for differences in adjusted linear trends between expansion and nonexpansion states before the expansions. See appendix exhibit D for further details.30

We also explored whether changes in the preconception health indicators measured in PRAMS may have reflected changes in the composition of women giving birth as a result of the ACA Medicaid expansions. For example, better access to contraception or family planning services under the Medicaid expansions could affect the timing and frequency of births and, therefore, the characteristics of women observed in PRAMS. To investigate this, we examined whether there were changes in the observable characteristics (age, race/ethnicity, education, and family composition) of low-income women with a recent live birth that were associated with the Medicaid eligibility expansions, using the difference-in-differences model described earlier.

Limitations

This study had several limitations. First, although our specification treated Medicaid eligibility expansions as a quasi-experiment, Medicaid expansion was not randomly assigned. Thus, potential confounding from unobserved, concurrent changes that varied by state may have affected our results. Second, income levels were calculated using the midpoints of discrete bins reported in the BRFSS and PRAMS, leading to some mismeasurement of which respondents were Medicaid expansion eligible, which may have attenuated our estimates. Third, although we use the same data sources used by the CDC to track this set of preconception health indicators, these data are subject to self-report bias or recall bias, which could vary in unknown ways across respondents. Fourth, as a result of limited sample sizes, we did not examine heterogeneity in the impact of Medicaid eligibility expansions on preconception health outcomes by race, ethnicity, parental status, or health status. These would be important directions for future research, given documented differences in perinatal insurance coverage by race, ethnicity, and parental status.14,33 Fifth, we were not able to adjust for multiple comparisons in our analyses.

Finally, analyses with the PRAMS used data from participating states only (see appendix exhibit C) and might not necessarily represent the experiences of women in other states.30 In addition, this data source samples women with recent live births and did not allow us to directly test for any changes in fertility in response to the Medicaid expansions. However, in supplemental analyses, we found no significant changes in the observable characteristics of mothers associated with Medicaid expansion during our study period (see appendix exhibit E).30 This suggests that changes observed in the following analyses were not driven by changes in the composition of women giving birth associated with the policy change.

Study Results

Preconception Health Indicators

Exhibit 1 compares the characteristics of low-income women of reproductive age across expansion and nonexpansion states before Medicaid expansions. A smaller proportion of women in the sample were Hispanic in nonexpansion states than in expansion states. In addition, women with a recent live birth were younger in nonexpansion states than in expansion states.

Exhibit 1 Baseline characteristics of low-income women, by state Medicaid expansion status

Characteristics Expansion states Nonexpansion states
Women of reproductive age (BRFSS)a
Number of observations 27,118 23,094
Age, years, mean (SD) 31.4 (6.9) 31.7 (7.3)
Race/ethnicity (%)
 White, non-Hispanic 40.6 39.8
 Black, non-Hispanic 15.2 25.0
 Other, non-Hispanic 8.4 5.0
 Hispanic 35.9 30.1
Education (%)
 Less than high school 29.0 26.9
 High school 30.3 32.5
 Some college 32.2 32.7
 College or more 8.4 8.0
Family composition
 Married (%) 31.8 34.1
 Number of children, mean (SD) 1.9 (1.4) 2.0 (1.5)
Women with a recent live birth (PRAMS)
Number of observations 9,121 5,917
Age, years (%)
 20–24 34.3 42.9
 25–29 32.3 32.7
 30–34 21.1 16.5
 35–39 9.9 6.2
 40+ 2.4 1.8
Race/ethnicity (%)
 White, non-Hispanic 40.8 64.1
 Black, non-Hispanic 20.5 12.4
 Other, non-Hispanic 9.4 10.3
 Hispanic 29.4 13.2
Years of education (%)
 <12 23.0 21.9
 12 37.3 35.9
 13–15 31.3 33.3
 ≥16 8.4 8.9
Family composition
 Married (%) 37.8 43.8
 Number of previous live births, mean (SD) 1.4 (1.0) 1.3 (1.3)

Exhibit 2 reports estimated changes in preconception health indicators among low-income women associated with the ACA Medicaid expansions. Among nonpregnant women of reproductive age, there were no significant changes in any of the health indicators (depression, diabetes, hypertension, current smoking, weight, and physical activity).

Exhibit 2 Changes in preconception health indicators for low-income women associated with Affordable Care Act Medicaid expansions

Difference-in-differences estimate
Health indicators Baseline mean in expansion states (%) Percentage-point change (95% CI)
Women of reproductive age (BRFSS)a
Depression 27.5 1.1 (−1.5, 3.6)
Diabetes 5.1 −0.1 (−0.8, 0.7)
Hypertension 13.8 0.5 (−1.0, 2.1)
Current smoking 27.6 −0.7 (−2.3, 0.9)
Normal weight 35.1 0.8 (−0.2, 1.8)
Recommended physical activity 46.4 1.6 (−1.7, 4.8)
Women with a recent live birth (PRAMS)
Preconception health counseling 18.1 4.0** (0.8, 7.0)
Folic acid intake 19.6 1.9** (0.2, 4.8)
Unwanted pregnancy 11.9 −2.1 (−8.5, 4.5)
Postpartum use of effective contraception 53.4 3.8** (0.3, 11.0)

Among low-income women with a recent live birth, there were significant improvements in three preconception health indicators that were associated with Medicaid expansion. There was a significant increase in the share of women reporting a preconception health conversation with a health care provider before pregnancy of 4 percentage points, or a 22 percent increase over the baseline mean. In addition, the share of women reporting daily folic acid intake (via a multivitamin, prenatal vitamin, or folic acid supplement) in the month before pregnancy increased by 1.9 percentage points, or a 9.7 percent increase over the baseline rate. Finally, the use of effective methods of contraception during the postpartum period increased by 3.8 percentage points, or a 7.1 percent increase over baseline.

Insurance Coverage

Exhibit 3 presents findings from analyses of secondary outcomes among low-income women with a recent live birth. Medicaid coverage increased during the preconception and postpartum periods by 11.1 percentage points and 8.5 percentage points, respectively, after Medicaid expansion. These increases did not, however, translate into statistically significant decreases in the overall uninsurance rate during these periods.

Exhibit 3 Changes in prepregnancy and postpartum coverage for low-income women associated with Medicaid expansions

Difference-in-differences estimate
Baseline mean in expansion states (%) Percentage-point change (95% CI)
Prepregnancy health insurance
No insurance coverage 34.6 −8.2 (−17.7, 3.9)
Medicaid coverage 38.3 11.1** (0.7, 18.1)
Postpartum health insurance
No insurance coverage 23.2 −5.7 (−20.8, 0.5)
Medicaid coverage 70.5 8.5*** (3.2, 24.5)

Sensitivity Analyses

Tests for differential pre-period trends suggested the validity of the research design and causal interpretation of these findings. Examining our outcomes of interest before the onset of Medicaid eligibility expansions, we found no evidence of significant differences in trends between the two groups of states in the pre period for the outcomes studied (see appendix exhibits F–H).30 These tests, however, do not definitively rule out the presence of differences in pre trends, which may bias the estimated effects of Medicaid expansion.

Discussion

We provide new evidence that expanded Medicaid coverage led to improvements in addressing preconception health risks.

We provide new evidence that expanded Medicaid coverage led to improvements in addressing certain preconception health risks among low-income women. First, we found that state Medicaid expansions were associated with increased receipt of preconception health counseling—that is, a conversation targeted to addressing key risks such as smoking, depression, or uncontrolled diabetes and hypertension before conception. Our estimate indicates that expanded Medicaid increased the likelihood that a low-income woman received preconception health counseling by 22 percent. This is important because it is estimated that half of pregnancies in the United States are affected by chronic health and behavioral risk factors that increase the risk for adverse maternal and infant outcomes34,35 and for which effective preconception medical interventions exist.21,22,3638

Second, we documented an increase in the proportion of low-income women who reported daily folic acid intake during the month before conception associated with Medicaid expansion. Recommended by the US Preventive Services Task Force for all women capable of having children, daily folic acid intake reduces the likelihood of neural tube defects among newborns.21,22 Our estimate indicates that expanded Medicaid coverage increased daily folic acid intake by nearly 10 percent among low-income women.

Finally, we document that the ACA Medicaid expansions led to increased use of effective birth control methods after childbirth among low-income women, which may decrease the likelihood of future unplanned pregnancies or short interpregnancy intervals. We estimate that expanded Medicaid coverage increased effective postpartum contraception use by 7 percent among low-income women.

We did not find any evidence, however, that the ACA Medicaid expansions were associated with changes in preconception health indicators related to chronic disease or other health behaviors among low-income women. This is consistent with prior research that found no impact of Medicaid eligibility expansions on body mass index or on diagnoses of diabetes or hypertension for women of reproductive age.16 Our data span five years after the Medicaid expansions, but this window may be too short to expect detectable changes in the prevalence of chronic conditions or many health behaviors. Although the changes we did observe were not statistically significant, the confidence intervals on our estimates included values that could be considered clinically meaningful changes.

Even if coverage does not change the prevalence of risky health conditions in the short term, it can improve the uptake of proper treatment and management of these conditions,19 which may also have important implications for maternal and infant health. Supporting this possibility, prior research suggests that treatment of diabetes increased under the ACA Medicaid expansions,3941 as did treatment of diabetes and hypertension among women of reproductive age, even as diagnosis rates for these conditions did not change.16

These findings have direct relevance to ongoing policy discussions. We provide the first evidence that the ACA Medicaid expansions led to increased preconception health counseling, folic acid intake, and effective postpartum contraception use. In addition, our results for contraception use, which asked respondents about their use at the time of interview (at least two to four months after delivery), indicate that expanded Medicaid coverage also affects postpartum health care use. Expanded postpartum coverage, such as the national extensions in postpartum Medicaid coverage that were recently proposed as part of a bipartisan bill in Congress,42 may help increase continuity of insurance coverage during this critical window and promote the receipt of recommended postpartum care.26

ACA Medicaid expansions can help address some of the risk factors that shape maternal and child health.

In sum, ACA Medicaid expansions—a public policy still under active debate in many states—can help address some of the risk factors that shape maternal and child health in the United States.

ACKNOWLEDGMENTS

A version of this manuscript was presented at the Association of Public Policy Analysis and Management Fall Research Conference in Denver, Colorado, November 8, 2019. Rebecca Myerson received support for her work on this article from the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health; the Office of the Director, National Institutes of Health; and the National Cancer Institute (NCI) under Award No. K12HD101368. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Myerson received grant funding for investigator-initiated research from Bristol-Myers Squibb from 2018 to 2019. Samuel Crawford has equity holdings with Gilead, Amgen, Allogene, and Bluebird Bio. Laura Wherry received support for her work on this article from a grant under the Robert Wood Johnson Foundation’s Policies for Action program. The authors acknowledge the PRAMS Working Group and the Centers for Disease Control and Prevention for assistance in accessing and interpreting the PRAMS data. They are grateful to Koray Caglayan and participants in the 2019 Association for Public Policy Analysis and Management fall research conference for helpful discussions, and to Jiren Sun for excellent research assistance.

NOTES

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