Abstract
Health insurance is critical for making health care affordable and accessible to women at all stages of life. Reproductive-aged women have long had higher rates of uninsurance than older women or men of the same age. 1,2 The Affordable Care Act (ACA) included several provisions to improve coverage among the U.S. population, including allowing individuals to stay on their parent's insurance plan until age 26 years; establishment of an insurance Marketplace with income-based subsidies; and the expansion of Medicaid to low-income adults earning up to 138% of the federal poverty level (FPL). These policies led to significant insurance gains among reproductive-aged women; however, the effects varied by state: women living in states that participated in the ACA Medicaid expansion saw a 52% decrease in uninsurance compared with a 28% decrease in states that chose not to expand. 3 –5
The decision not to expand Medicaid represents a significant missed opportunity to support the health of reproductive-aged and pregnant women. In this issue of the Journal of Women's Health, Taylor et al. report the results of an observational study comparing preventive care use and birth outcomes by insurance status in North Carolina (NC), 1 of 14 states that have not implemented the ACA Medicaid expansion as of August 2019. 6
Understanding the policy context is important for interpretation of this study. In NC, low-income women earning up to 196% FPL qualify for Medicaid coverage while they are pregnant from conception to 2 months after delivery ($41,806 for a family of three in 2019). Women only qualify for coverage before and after pregnancy Medicaid if they have a dependent child living in the household and a very low income (42% FPL or $8,958 in 2019). 7 If a woman does not qualify for Medicaid and does not have access to a plan from a spouse or employer, she must obtain a plan on the ACA Marketplaces. However, affording the premiums and cost sharing associated with a Marketplace plan can be a challenge especially if she falls in the ACA coverage gap (from 42% to 100% FPL in NC). Women in this income range earn too much to qualify for Medicaid but too little to qualify for a Marketplace subsidy (which only cover individuals 100%–400% FPL). This puts low-income women at risk of going uninsured both preconception and postpartum, periods when access to physical and mental health care is critical for reducing risk factors that contribute to maternal and infant morbidity and mortality.
Using data from a large NC health system, Taylor et al. document the insurance-related disparities in access to care that can result from this policy arrangement. They find that pregnant Medicaid beneficiaries attended a quarter of the preconception well-woman visits received by privately insured women. They also found that compared with privately insured women, Medicaid beneficiaries were 18% more likely to receive late prenatal care, 3 times more likely to have a prenatal emergency department visit, and 1.5 times more likely not to attend the recommended 6-week postpartum follow-up visit.
This study is cross-sectional and thus these differences should not be interpreted as the causal effect of insurance status per se. There are many sociodemographic, health, and attitudinal differences between women who are insured by Medicaid and private insurance that would contribute to the observed differences. Furthermore, the authors do not find any significant differences in birth outcomes such as preterm birth and low-birth weight by insurance status. However, the striking magnitude of the insurance-related disparities in receipt of preventive and recommended care should at least give us pause to consider the opportunities to improve health care access for Medicaid beneficiaries before and after pregnancy.
One driver of lower access is likely to be the insurance policies previously described that leave low-income women with limited insurance options before and after pregnancy, especially in Medicaid nonexpansion states. The authors offer several constructive suggestions for reform, including the expansion of pregnancy Medicaid coverage from 2 to 12 months postpartum. This could lead to significant improvements in postpartum coverage and has recently been proposed at both the federal and state levels. 8 Nonexpansion states could also opt to implement the ACA Medicaid expansion, which studies have found was associated with increased preconception coverage. 9
Lack of a continuous source of coverage from preconception to postpartum is only one barrier that may lead to lower rates of preventive health care use among Medicaid beneficiaries. Advancing access to high-quality health care for women through all stages of life—not only when they are pregnant—will require interventions in the clinical, community, and policy spheres. Even with insurance, low-income women may face particular challenges getting to appointments due to lack of transportation and childcare and finding providers that engage in culturally competent care. Women may also face implicit bias and discrimination—on the basis of insurance status, race, language or other factors—that undermines the quality of care received and trust in the health care system. Efforts to reduce disparities in health care use and quality should be informed by listening to, and valuing, women's first-hand experiences navigating the health insurance and health care delivery system.