Medicaid Expansion and Perinatal Health Outcomes: A Quasi-Experimental Study

ObjectiveThere has been little evidence of the impact of preventive services during pregnancy covered under the Affordable Care Act (ACA) on birthing parent and infant outcomes. To address this gap, this study examines the association between Medicaid expansion under the ACA and birthing parent and infant outcomes of low-income pregnant people.MethodsThis study used individual-level data from the 2004-2017 annual waves of the Pregnancy Risk Assessment Monitoring System (PRAMS). PRAMS is a surveillance project of the Centers for Disease Control and Prevention and health departments that annually includes a representative sample of 1,300 to 3,400 births per state, selected from birth certificates. Birthing parents' outcomes of interest included timing of prenatal care, gestational diabetes, hypertensive disorders of pregnancy, cigarette smoking during pregnancy, and postpartum care. Infant outcomes included initiation and duration of breastfeeding, preterm birth, and birth weight. The association between ACA Medicaid expansion and the birthing parent and infant outcomes were examined using difference-in-differences estimation.ResultsThere was no association between Medicaid expansion and the outcomes examined after correcting for multiple testing. This finding was robust to several sensitivity analyses.Conclusions for PracticeStudy findings suggest that expanded access to more complete insurance benefits with limited cost-sharing for pregnant people, a group that already had high rates of insurance coverage, did not impact the birthing parents' and infant health outcomes examined. Pregnant people had high rates of insurance coverage before the Affordable Care Act, but insurance instability remains high during the perinatal period. The ACA made a substantial number of changes to the cost-sharing of preventive benefits for pregnant people. There is limited research on changes in outcomes related to new preventive benefits for pregnant people.We examined several perinatal outcomes for low-income pregnant people after full enactment of ACA provisions. We find little change in the outcomes examined. Results suggest that ACA policies and insurance expansion that predate the ACA were necessary but insufficient to improve these more intractable outcomes.