Rural-Urban Differences in Health Care Unaffordability During the Postpartum Period
Medical Care, Aug 10, 2023
Objective: The objective of this study was to examine health care unaffordability for rural and u... more Objective: The objective of this study was to examine health care unaffordability for rural and urban residents and by postpartum status. Methods: We used cross-sectional survey data on female-identifying respondents ages 18–44 (n=17,800) from the 2019 to 2021 National Health Interview Study. Outcomes of interest were 3 measures of health care unaffordability. We conducted bivariate and multivariable regression models to assess the association between health care unaffordability, rurality, and postpartum status. Results: Bivariate analyses showed postpartum people reported statistically significantly higher rates of being unable to pay medical bills and having problems medical paying bills, as compared with nonpostpartum people. Rural residents also reported statistically significantly higher rates of being unable to pay their medical bills and having problems paying medical bills as compared with urban residents. In adjusted models, the predicted probability of being unable to pay medical bills among postpartum respondents was 12.8% (CI, 10.1–15.5), which was statistically significantly higher than among nonpostpartum respondents. Similarly, postpartum respondents had statistically significantly higher predicted probabilities of reporting problems paying medical bills (18.4%, CI, 15.4–21.4) as compared with nonpostpartum respondents. The rural residency was not significantly associated with the health care unaffordability outcome measures in adjusted models. Conclusions: Both postpartum and rural respondents reported higher rates of being unable to pay medical bills and having problems paying medical bills; however, after adjusting for covariates, only postpartum respondents reported statistically significantly higher rates of these outcomes. These results suggest that postpartum status may present challenges to health care affordability that span the urban/rural context.
Association of Affordable Care Act Medicaid Expansions with Births Among Low-Income Women of Reproductive Age
Journal of Womens Health, Jul 1, 2022
Background: This study examined the association between Medicaid expansions under the Affordable ... more Background: This study examined the association between Medicaid expansions under the Affordable Care Act (ACA) and births among low-income women of reproductive age in the United States. Methods: We used data from the 2008 to 2019 American Community Survey to estimate the association between state adoption of Medicaid expansion under the ACA and the percent of low-income women of reproductive age with a birth in the past year using a difference-in-difference research design. Subgroup analysis was explored by race and ethnicity, age group, educational attainment, marital status, and number of children. Results: We found that Medicaid expansion was associated with a small reduction in births among low-income women of reproductive age by 0.45 percentage points (95% confidence interval: -0.84 to -0.05). In subgroup analyses, we found reductions in births among Hispanic women, American Indian or Alaska Native women, women 25-29 years of age, women 35-39 years of age, unmarried women, and women with more than three children. Conclusions: Reductions in births associated with Medicaid expansion could suggest that expanding Medicaid addressed previously unmet reproductive health care needs among low-income women of reproductive age. The reductions in births among low-income women that we observe were occurring among some groups with higher unintended pregnancy rates, including Hispanic women, American Indian or Alaska Native women, young women, and unmarried women. These findings underscore the importance of reproductive health care access through insurance coverage on empowering women to have control over their reproductive decision-making and timing.
Association of the affordable care act Medicaid expansions with postpartum contraceptive use and early postpartum pregnancy
Contraception, Sep 1, 2022
OBJECTIVES Before the Affordable Care Act (ACA), 55 percent of individuals giving birth with Medi... more OBJECTIVES Before the Affordable Care Act (ACA), 55 percent of individuals giving birth with Medicaid lost insurance postpartum, potentially affecting their access to postpartum contraception. We evaluate the association of the ACA Medicaid expansions with postpartum contraceptive use and pregnancy at the time of the survey. METHODS We used 2012-2019 Pregnancy Risk Assessment Monitoring System data to estimate difference-in-difference models for the association of Medicaid expansions with use of postpartum contraception (mean: 4 months postpartum): any contraception, long-acting reversible contraception or LARC (contraceptive implant and intrauterine device), short-acting (contraceptive pill, patch, and ring), permanent, or non-prescription methods (condoms, rhythm method, and withdrawal), and pregnancy at the time of the survey. We examine low-income respondents overall and stratified by race and ethnicity. RESULTS We find that Medicaid expansion was associated with a 7.0 percentage point (95% CI: 3.0, 11.0) increase in postpartum LARC, a 3.1 percentage point (95% CI: -6.0, -0.2) decrease in short-acting contraception, and a 3.9 percentage point (95% CI: -6.2, -1.5) decrease in non-prescription contraceptive use overall. In stratified analyses, we find that increases in LARC use was concentrated among non-Hispanic White and Black respondents, with shifts in other postpartum contraceptives towards LARCs. Medicaid expansion was associated with a decrease in early postpartum pregnancy only among non-Hispanic Black respondents. CONCLUSIONS Medicaid expansions led to shifts from methods with lower upfront out-of-pocket cost for people without insurance towards methods with higher upfront out-of-pocket cost for people without insurance. These changes suggest that Medicaid expansion improved postpartum contraceptive access.
This cross-sectional study uses Pregnancy Risk Assessment Monitoring System data to investigate t... more This cross-sectional study uses Pregnancy Risk Assessment Monitoring System data to investigate the association between marketplace pregnancy special enrollment and prenatal insurance coverage in New York.
Introduction: The COVID-19 public health emergency created unprecedented disruptions in the use o... more Introduction: The COVID-19 public health emergency created unprecedented disruptions in the use of healthcare services, which could have affected long-standing racial-ethnic disparities in maternal care use and outcomes. This study evaluates population-level changes in perinatal health services associated with the COVID-19 pandemic overall and by maternal race-ethnicity. Methods: In this analysis of all U.S. live births from 2016 to 2020, interrupted time-series analysis was used to estimate the change in the mean number of prenatal care visits and rates of hospital birth, labor induction, and cesarean delivery associated with the start of the pandemic (March 2020) overall and by maternal race-ethnicity. Analyses were conducted in 2022. Results: The start of the pandemic was associated with overall decreases in the mean number of prenatal care visits, decreases in hospital birth rates, and increases in labor induction rates. The mean number of prenatal care visits decreased similarly for all racial-ethnic groups, whereas reductions in hospital births were largest for non-Hispanic White individuals, and increases in labor induction were largest for non-Hispanic White and non-Hispanic Asian or Pacific Islander individuals. Conclusions: Among all U.S. live births, the COVID-19 pandemic was associated with modest overall changes in perinatal care, with differential changes by maternal race-ethnicity. Differential changes in perinatal services may have implications for racial−ethnic maternal health disparities.
This study's limitations include that the CPS-ASEC has historically undercounted people with Medi... more This study's limitations include that the CPS-ASEC has historically undercounted people with Medicaid. 5 Also, for early postpartum respondents, coverage during the past year may not necessarily reflect coverage during pregnancy or the 60 days postpartum because the past year covered preconception, pregnancy, and early postpartum. Currently, the Families First Coronavirus Response Act is set to expire in April 2022. Passage of legislation, which is under consideration in many states, to extend pregnancy-related Medicaid through 1 year postpartum is necessary to maintain pandemic-era gains in postpartum insurance continuity. 6
The regulatory connections between the circadian clock and hormone signaling are essential to und... more The regulatory connections between the circadian clock and hormone signaling are essential to understand, as these two regulatory processes work together to time growth processes relative to predictable environmental events. Gibberellins (GAs) are phytohormones that control many growth processes throughout all stages of the plant life cycle, including germination and flowering. An increasing number of examples demonstrate that the circadian clock directly influences GA biosynthesis and signaling. EARLY FLOWERING 3 (ELF3) participates in a tripartite transcriptional complex known as the Evening Complex (EC). In this capacity, ELF3 is fundamental to core circadian clock activity, as well as time-of-day specific regulation of genes directly responsible for growth control, namely the PHYTOCHROME INTERACTING FACTOR 4 (PIF4) and PIF5 genes. Here we show that the GA biosynthesis inhibitor paclobutrazol substantially reduces the long hypocotyl and petiole phenotypes of Arabidopsis elf3 mutants. In addition, loss of ELF3 activity causes upregulation of the key GA biosynthesis genes GA20ox1 and GA20ox2. Moreover, GA20ox1 and GA20ox2 expression depends strongly on the redundant activities of PIF4 and PIF5. These findings indicate that the defining growth phenotypes of elf3 mutants arise from altered GA biosynthesis due to misregulation of PIF4 and PIF5. These observations agree with recent work linking increased GA production with the elongated growth phenotypes of the barley elf3 mutant. Thus, the role of the EC in regulation of GA biosynthesis and signaling in eudicots is shared with monocots and, therefore, is a highly conserved mechanism for growth control.
IMPORTANCE Policy makers are considering insurance expansions to improve maternal health. The tra... more IMPORTANCE Policy makers are considering insurance expansions to improve maternal health. The tradeoffs between expanding Medicaid or subsidized private insurance for maternal coverage and care are unknown. OBJECTIVE To compare maternal coverage and care by Medicaid vs marketplace eligibility. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study using a difference-indifference research design was conducted from March 14, 2020, to April 22, 2021. Maternal coverage and care use were compared among women with family incomes 100% to 138% of the federal poverty level (FPL) residing in 10 Medicaid expansion sites (exposure group) who gained Medicaid eligibility under the Affordable Care Act and in 5 nonexpansion sites (comparison group) who gained marketplace eligibility before (2011-2013) and after (2015-2018) insurance expansion implementation. Participants included women aged 18 years or older from the 2011-2018 Pregnancy Risk Assessment Monitoring System survey. EXPOSURES Eligibility for Medicaid or marketplace coverage under the Affordable Care Act. MAIN OUTCOMES AND MEASURES Outcomes included coverage in the preconception and postpartum periods, early and adequate prenatal care, and postpartum checkups and effective contraceptive use. RESULTS The study population included 11 432 women age 18 years and older (32% age 18-24 years, 33% age 25-29 years, 35% age Ն30 years) with incomes 100% to 138% FPL: 7586 in a Medicaid state (exposure group) and 3846 in a nonexpansion marketplace state (comparison group). Women in marketplace states were younger, had higher educational level and marriage rates, and had less racial and ethnic diversity. Medicaid relative to marketplace eligibility was associated with increased Medicaid coverage (20.3 percentage points; 95% CI, 12.8 to 30.0 percentage points), decreased private insurance coverage (−10.8 percentage points; 95% CI, −13.3 to −7.5 percentage points), and decreased uninsurance (−8.7 percentage points; 95% CI, −20.1 to −0.1 percentage points) in the preconception period, increased postpartum Medicaid (17.4 percentage points; 95% CI, 1.7 to 34.3 percentage points) and increased adequate prenatal care (4.4 percentage points; 95% CI, 0.1 to 11.0 percentage points) in difference-indifference models. No evidence of significant differences in early prenatal care, postpartum checkups , or postpartum contraception was identified. CONCLUSIONS AND RELEVANCE In this cohort study, eligibility for Medicaid was associated with increased Medicaid, lower preconception uninsurance, and increased adequate prenatal care use. The lower rates of preconception uninsurance among Medicaid-eligible women suggest that women with low incomes were facing barriers to marketplace enrollment, underscoring the potential (continued) Key Points Question How does preconception and postpartum coverage and care use compare among women with low incomes gaining eligibility for Medicaid vs marketplace coverage? Findings In this cohort study of 11 432 women with low incomes, Medicaid eligibility relative to marketplace eligibility was associated with significantly increased Medicaid coverage (20.3 percentage points), decreased private insurance coverage (−10.8 percentage points), and decreased uninsurance (−8.7 percentage points) in the preconception period. It was also associated with increased postpartum Medicaid (17.4 percentage points) and increased adequate prenatal care (4.4 percentage points) but not with significant changes in early prenatal care, postpartum checkups, or postpartum contraception. Meaning The finding of lower rates of preconception uninsurance among Medicaid-eligible women in this study suggests that women with low incomes were facing barriers to marketplace enrollment.
The Effects of Health Insurance Eligibility Policies on Maternal Care Access and Childbirth Outcomes
This dissertation examines three health insurance eligibility policies and their impact on reprod... more This dissertation examines three health insurance eligibility policies and their impact on reproductive health outcomes for low-income women of reproductive age. The first paper examines the effects of expanded eligibility for Medicaid under the Affordable Care Act (ACA), on fertility among low-income women of childbearing age. The second paper explores the effect of presumptive eligibility policies in Medicaid for pregnant women on access to prenatal care and health insurance coverage. Finally, the third paper exploits state-level differences in eligibility for public versus private insurance under the ACA, and the effects on perinatal coverage patterns, childbirth outcomes, and access to care.
Mental Health and Postpartum Care in California: Implications from California's Provisional Postpartum Care Extension
Women's Health Issues, 2021
California's Provisional Postpartum Care Extension (PPCE) extended Medicaid eligibility throu... more California's Provisional Postpartum Care Extension (PPCE) extended Medicaid eligibility through 1 year postpartum for women enrolled in Medi-Cal with annual household incomes of 138%-322% of the federal poverty level and maternal mental health diagnoses. For this cross-sectional descriptive study, we used the 2017 Listening to Mothers in California survey of postpartum women to identify those potentially eligible for PPCE. We then sought to describe their demographic characteristics, self-reported mental health, and utilization of postpartum care and mental health services compared with those with Medi-Cal during pregnancy who did not meet PPCE eligibility criteria. Overall, potentially PPCE-eligible women comprised 6.8% of respondents. Among those who did not qualify for PPCE, the primary reason was the absence of self-reported maternal mental health symptoms. Potentially PPCE-eligible women were approximately two-thirds Hispanic/Latina and more than one-third were ages 25 to 29. The most common self-reported mental health symptom was anxiety during pregnancy (78.9%). Among potentially PPCE-eligible women, 8.4% were taking medicine for anxiety/depression postpartum and 16.0% were receiving postpartum counseling/treatment for emotional or mental well-being. Our analyses suggest that PPCE could have extended postpartum coverage eligibility for approximately 30,360 women statewide. However, our findings demonstrate how narrowly defined PPCE eligibility criteria likely excluded many postpartum women in Medi-Cal who would have been left with limited benefits or more cost-sharing under alternative coverage options. This research could inform state and federal policymakers considering other proposals to extend postpartum Medicaid eligibility.
Evictions are increasingly recognized as a serious concern facing low-income households. This stu... more Evictions are increasingly recognized as a serious concern facing low-income households. This study evaluated whether expansions of Medicaid can prevent evictions from occurring. We examined data from a privately licensed database of eviction records in fourteen states (286 counties) and used a difference-indifferences research design to compare rates of eviction before and after California's early Medicaid expansion (51 counties). Early Medicaid expansion in California was associated with a reduction in the number of evictions, with 24.5 fewer evictions per month in each county from a pre-expansion average of 224.7. These results imply that for every thousand new Medicaid enrollees in California, Medicaid expansion was associated with roughly twenty-two fewer evictions per year. Additionally, we found a 2.9-percentage-point reduction in evictions per capita associated with early expansion. The effects were concentrated among counties with the highest pre-expansion rates of uninsurance. We conclude that health insurance coverage is associated with improved housing stability.
Rural-Urban Differences in Health Care Unaffordability During the Postpartum Period
Medical Care, Aug 10, 2023
Objective: The objective of this study was to examine health care unaffordability for rural and u... more Objective: The objective of this study was to examine health care unaffordability for rural and urban residents and by postpartum status. Methods: We used cross-sectional survey data on female-identifying respondents ages 18–44 (n=17,800) from the 2019 to 2021 National Health Interview Study. Outcomes of interest were 3 measures of health care unaffordability. We conducted bivariate and multivariable regression models to assess the association between health care unaffordability, rurality, and postpartum status. Results: Bivariate analyses showed postpartum people reported statistically significantly higher rates of being unable to pay medical bills and having problems medical paying bills, as compared with nonpostpartum people. Rural residents also reported statistically significantly higher rates of being unable to pay their medical bills and having problems paying medical bills as compared with urban residents. In adjusted models, the predicted probability of being unable to pay medical bills among postpartum respondents was 12.8% (CI, 10.1–15.5), which was statistically significantly higher than among nonpostpartum respondents. Similarly, postpartum respondents had statistically significantly higher predicted probabilities of reporting problems paying medical bills (18.4%, CI, 15.4–21.4) as compared with nonpostpartum respondents. The rural residency was not significantly associated with the health care unaffordability outcome measures in adjusted models. Conclusions: Both postpartum and rural respondents reported higher rates of being unable to pay medical bills and having problems paying medical bills; however, after adjusting for covariates, only postpartum respondents reported statistically significantly higher rates of these outcomes. These results suggest that postpartum status may present challenges to health care affordability that span the urban/rural context.
Association of Affordable Care Act Medicaid Expansions with Births Among Low-Income Women of Reproductive Age
Journal of Womens Health, Jul 1, 2022
Background: This study examined the association between Medicaid expansions under the Affordable ... more Background: This study examined the association between Medicaid expansions under the Affordable Care Act (ACA) and births among low-income women of reproductive age in the United States. Methods: We used data from the 2008 to 2019 American Community Survey to estimate the association between state adoption of Medicaid expansion under the ACA and the percent of low-income women of reproductive age with a birth in the past year using a difference-in-difference research design. Subgroup analysis was explored by race and ethnicity, age group, educational attainment, marital status, and number of children. Results: We found that Medicaid expansion was associated with a small reduction in births among low-income women of reproductive age by 0.45 percentage points (95% confidence interval: -0.84 to -0.05). In subgroup analyses, we found reductions in births among Hispanic women, American Indian or Alaska Native women, women 25-29 years of age, women 35-39 years of age, unmarried women, and women with more than three children. Conclusions: Reductions in births associated with Medicaid expansion could suggest that expanding Medicaid addressed previously unmet reproductive health care needs among low-income women of reproductive age. The reductions in births among low-income women that we observe were occurring among some groups with higher unintended pregnancy rates, including Hispanic women, American Indian or Alaska Native women, young women, and unmarried women. These findings underscore the importance of reproductive health care access through insurance coverage on empowering women to have control over their reproductive decision-making and timing.
Association of the affordable care act Medicaid expansions with postpartum contraceptive use and early postpartum pregnancy
Contraception, Sep 1, 2022
OBJECTIVES Before the Affordable Care Act (ACA), 55 percent of individuals giving birth with Medi... more OBJECTIVES Before the Affordable Care Act (ACA), 55 percent of individuals giving birth with Medicaid lost insurance postpartum, potentially affecting their access to postpartum contraception. We evaluate the association of the ACA Medicaid expansions with postpartum contraceptive use and pregnancy at the time of the survey. METHODS We used 2012-2019 Pregnancy Risk Assessment Monitoring System data to estimate difference-in-difference models for the association of Medicaid expansions with use of postpartum contraception (mean: 4 months postpartum): any contraception, long-acting reversible contraception or LARC (contraceptive implant and intrauterine device), short-acting (contraceptive pill, patch, and ring), permanent, or non-prescription methods (condoms, rhythm method, and withdrawal), and pregnancy at the time of the survey. We examine low-income respondents overall and stratified by race and ethnicity. RESULTS We find that Medicaid expansion was associated with a 7.0 percentage point (95% CI: 3.0, 11.0) increase in postpartum LARC, a 3.1 percentage point (95% CI: -6.0, -0.2) decrease in short-acting contraception, and a 3.9 percentage point (95% CI: -6.2, -1.5) decrease in non-prescription contraceptive use overall. In stratified analyses, we find that increases in LARC use was concentrated among non-Hispanic White and Black respondents, with shifts in other postpartum contraceptives towards LARCs. Medicaid expansion was associated with a decrease in early postpartum pregnancy only among non-Hispanic Black respondents. CONCLUSIONS Medicaid expansions led to shifts from methods with lower upfront out-of-pocket cost for people without insurance towards methods with higher upfront out-of-pocket cost for people without insurance. These changes suggest that Medicaid expansion improved postpartum contraceptive access.
This cross-sectional study uses Pregnancy Risk Assessment Monitoring System data to investigate t... more This cross-sectional study uses Pregnancy Risk Assessment Monitoring System data to investigate the association between marketplace pregnancy special enrollment and prenatal insurance coverage in New York.
Introduction: The COVID-19 public health emergency created unprecedented disruptions in the use o... more Introduction: The COVID-19 public health emergency created unprecedented disruptions in the use of healthcare services, which could have affected long-standing racial-ethnic disparities in maternal care use and outcomes. This study evaluates population-level changes in perinatal health services associated with the COVID-19 pandemic overall and by maternal race-ethnicity. Methods: In this analysis of all U.S. live births from 2016 to 2020, interrupted time-series analysis was used to estimate the change in the mean number of prenatal care visits and rates of hospital birth, labor induction, and cesarean delivery associated with the start of the pandemic (March 2020) overall and by maternal race-ethnicity. Analyses were conducted in 2022. Results: The start of the pandemic was associated with overall decreases in the mean number of prenatal care visits, decreases in hospital birth rates, and increases in labor induction rates. The mean number of prenatal care visits decreased similarly for all racial-ethnic groups, whereas reductions in hospital births were largest for non-Hispanic White individuals, and increases in labor induction were largest for non-Hispanic White and non-Hispanic Asian or Pacific Islander individuals. Conclusions: Among all U.S. live births, the COVID-19 pandemic was associated with modest overall changes in perinatal care, with differential changes by maternal race-ethnicity. Differential changes in perinatal services may have implications for racial−ethnic maternal health disparities.
This study's limitations include that the CPS-ASEC has historically undercounted people with Medi... more This study's limitations include that the CPS-ASEC has historically undercounted people with Medicaid. 5 Also, for early postpartum respondents, coverage during the past year may not necessarily reflect coverage during pregnancy or the 60 days postpartum because the past year covered preconception, pregnancy, and early postpartum. Currently, the Families First Coronavirus Response Act is set to expire in April 2022. Passage of legislation, which is under consideration in many states, to extend pregnancy-related Medicaid through 1 year postpartum is necessary to maintain pandemic-era gains in postpartum insurance continuity. 6
The regulatory connections between the circadian clock and hormone signaling are essential to und... more The regulatory connections between the circadian clock and hormone signaling are essential to understand, as these two regulatory processes work together to time growth processes relative to predictable environmental events. Gibberellins (GAs) are phytohormones that control many growth processes throughout all stages of the plant life cycle, including germination and flowering. An increasing number of examples demonstrate that the circadian clock directly influences GA biosynthesis and signaling. EARLY FLOWERING 3 (ELF3) participates in a tripartite transcriptional complex known as the Evening Complex (EC). In this capacity, ELF3 is fundamental to core circadian clock activity, as well as time-of-day specific regulation of genes directly responsible for growth control, namely the PHYTOCHROME INTERACTING FACTOR 4 (PIF4) and PIF5 genes. Here we show that the GA biosynthesis inhibitor paclobutrazol substantially reduces the long hypocotyl and petiole phenotypes of Arabidopsis elf3 mutants. In addition, loss of ELF3 activity causes upregulation of the key GA biosynthesis genes GA20ox1 and GA20ox2. Moreover, GA20ox1 and GA20ox2 expression depends strongly on the redundant activities of PIF4 and PIF5. These findings indicate that the defining growth phenotypes of elf3 mutants arise from altered GA biosynthesis due to misregulation of PIF4 and PIF5. These observations agree with recent work linking increased GA production with the elongated growth phenotypes of the barley elf3 mutant. Thus, the role of the EC in regulation of GA biosynthesis and signaling in eudicots is shared with monocots and, therefore, is a highly conserved mechanism for growth control.
IMPORTANCE Policy makers are considering insurance expansions to improve maternal health. The tra... more IMPORTANCE Policy makers are considering insurance expansions to improve maternal health. The tradeoffs between expanding Medicaid or subsidized private insurance for maternal coverage and care are unknown. OBJECTIVE To compare maternal coverage and care by Medicaid vs marketplace eligibility. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study using a difference-indifference research design was conducted from March 14, 2020, to April 22, 2021. Maternal coverage and care use were compared among women with family incomes 100% to 138% of the federal poverty level (FPL) residing in 10 Medicaid expansion sites (exposure group) who gained Medicaid eligibility under the Affordable Care Act and in 5 nonexpansion sites (comparison group) who gained marketplace eligibility before (2011-2013) and after (2015-2018) insurance expansion implementation. Participants included women aged 18 years or older from the 2011-2018 Pregnancy Risk Assessment Monitoring System survey. EXPOSURES Eligibility for Medicaid or marketplace coverage under the Affordable Care Act. MAIN OUTCOMES AND MEASURES Outcomes included coverage in the preconception and postpartum periods, early and adequate prenatal care, and postpartum checkups and effective contraceptive use. RESULTS The study population included 11 432 women age 18 years and older (32% age 18-24 years, 33% age 25-29 years, 35% age Ն30 years) with incomes 100% to 138% FPL: 7586 in a Medicaid state (exposure group) and 3846 in a nonexpansion marketplace state (comparison group). Women in marketplace states were younger, had higher educational level and marriage rates, and had less racial and ethnic diversity. Medicaid relative to marketplace eligibility was associated with increased Medicaid coverage (20.3 percentage points; 95% CI, 12.8 to 30.0 percentage points), decreased private insurance coverage (−10.8 percentage points; 95% CI, −13.3 to −7.5 percentage points), and decreased uninsurance (−8.7 percentage points; 95% CI, −20.1 to −0.1 percentage points) in the preconception period, increased postpartum Medicaid (17.4 percentage points; 95% CI, 1.7 to 34.3 percentage points) and increased adequate prenatal care (4.4 percentage points; 95% CI, 0.1 to 11.0 percentage points) in difference-indifference models. No evidence of significant differences in early prenatal care, postpartum checkups , or postpartum contraception was identified. CONCLUSIONS AND RELEVANCE In this cohort study, eligibility for Medicaid was associated with increased Medicaid, lower preconception uninsurance, and increased adequate prenatal care use. The lower rates of preconception uninsurance among Medicaid-eligible women suggest that women with low incomes were facing barriers to marketplace enrollment, underscoring the potential (continued) Key Points Question How does preconception and postpartum coverage and care use compare among women with low incomes gaining eligibility for Medicaid vs marketplace coverage? Findings In this cohort study of 11 432 women with low incomes, Medicaid eligibility relative to marketplace eligibility was associated with significantly increased Medicaid coverage (20.3 percentage points), decreased private insurance coverage (−10.8 percentage points), and decreased uninsurance (−8.7 percentage points) in the preconception period. It was also associated with increased postpartum Medicaid (17.4 percentage points) and increased adequate prenatal care (4.4 percentage points) but not with significant changes in early prenatal care, postpartum checkups, or postpartum contraception. Meaning The finding of lower rates of preconception uninsurance among Medicaid-eligible women in this study suggests that women with low incomes were facing barriers to marketplace enrollment.
The Effects of Health Insurance Eligibility Policies on Maternal Care Access and Childbirth Outcomes
This dissertation examines three health insurance eligibility policies and their impact on reprod... more This dissertation examines three health insurance eligibility policies and their impact on reproductive health outcomes for low-income women of reproductive age. The first paper examines the effects of expanded eligibility for Medicaid under the Affordable Care Act (ACA), on fertility among low-income women of childbearing age. The second paper explores the effect of presumptive eligibility policies in Medicaid for pregnant women on access to prenatal care and health insurance coverage. Finally, the third paper exploits state-level differences in eligibility for public versus private insurance under the ACA, and the effects on perinatal coverage patterns, childbirth outcomes, and access to care.
Mental Health and Postpartum Care in California: Implications from California's Provisional Postpartum Care Extension
Women's Health Issues, 2021
California's Provisional Postpartum Care Extension (PPCE) extended Medicaid eligibility throu... more California's Provisional Postpartum Care Extension (PPCE) extended Medicaid eligibility through 1 year postpartum for women enrolled in Medi-Cal with annual household incomes of 138%-322% of the federal poverty level and maternal mental health diagnoses. For this cross-sectional descriptive study, we used the 2017 Listening to Mothers in California survey of postpartum women to identify those potentially eligible for PPCE. We then sought to describe their demographic characteristics, self-reported mental health, and utilization of postpartum care and mental health services compared with those with Medi-Cal during pregnancy who did not meet PPCE eligibility criteria. Overall, potentially PPCE-eligible women comprised 6.8% of respondents. Among those who did not qualify for PPCE, the primary reason was the absence of self-reported maternal mental health symptoms. Potentially PPCE-eligible women were approximately two-thirds Hispanic/Latina and more than one-third were ages 25 to 29. The most common self-reported mental health symptom was anxiety during pregnancy (78.9%). Among potentially PPCE-eligible women, 8.4% were taking medicine for anxiety/depression postpartum and 16.0% were receiving postpartum counseling/treatment for emotional or mental well-being. Our analyses suggest that PPCE could have extended postpartum coverage eligibility for approximately 30,360 women statewide. However, our findings demonstrate how narrowly defined PPCE eligibility criteria likely excluded many postpartum women in Medi-Cal who would have been left with limited benefits or more cost-sharing under alternative coverage options. This research could inform state and federal policymakers considering other proposals to extend postpartum Medicaid eligibility.
Evictions are increasingly recognized as a serious concern facing low-income households. This stu... more Evictions are increasingly recognized as a serious concern facing low-income households. This study evaluated whether expansions of Medicaid can prevent evictions from occurring. We examined data from a privately licensed database of eviction records in fourteen states (286 counties) and used a difference-indifferences research design to compare rates of eviction before and after California's early Medicaid expansion (51 counties). Early Medicaid expansion in California was associated with a reduction in the number of evictions, with 24.5 fewer evictions per month in each county from a pre-expansion average of 224.7. These results imply that for every thousand new Medicaid enrollees in California, Medicaid expansion was associated with roughly twenty-two fewer evictions per year. Additionally, we found a 2.9-percentage-point reduction in evictions per capita associated with early expansion. The effects were concentrated among counties with the highest pre-expansion rates of uninsurance. We conclude that health insurance coverage is associated with improved housing stability.
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Papers by Erica Eliason