Pregnancy Medicaid Improvements in a Nonexpansion State After the Affordable Care Act

With the Affordable Care Act just past its tenth anniversary, now seems a good time to celebrate its accomplishments. Swartz, Meskey, Stuart, and Rodriguez have demonstrated an aspect of the law’s success.1 After ACA implementation the proportion of women covered by Medicaid for Pregnant Women decreased in North Carolina and the proportion covered by full Medicaid increased. Full Medicaid continues coverage beyond two months postpartum, increasing linkage to a medical home, access to family planning, behavioral health, and chronic disease management. Women with dependent minors are eligible for full Medicaid with incomes under 40% of the Federal Poverty Limit or $8,784 for a family of three. The changes in Medicaid policy making this possible include #1) elimination of asset minimum requirements, #2) using modified adjusted gross income, and #3) using state data to verify income and an algorithmic enrollment system including data from public assistance programs. One finding that merits further examination is the dramatic decline in emergency Medicaid enrollment from 13% pre-ACA to 7% post ACA. The most important explanation may be the steady decline in the number of unauthorized immigrants from 2007 to 2016.2

The American Rescue Plan offers new opportunities for states to expand Medicaid coverage. Pregnancy-related Medicaid can be extended from 60 days to one year postpartum at the current federal match. Rising U.S. maternal mortality rates, especially among low-income women and women of color, underscore a maternal health crisis. With 12% of pregnancy-related deaths occurring between six weeks and one year postpartum, expanded postpartum Medicaid coverage can reduce pregnancy-related mortality by ensuring access to vital services to support mothers’ physical, mental and emotional health and wellbeing.3 Closing coverage gaps can improve access to lactation support4 and family planning services. Supporting maternal health extends benefits to the next generation, with improved health for infants. Black and Latinx women are disproportionately represented among Medicaid enrollees, and expanding postpartum Medicaid provides a necessary tool to address maternal and infant health disparities. For nonexpansion states, the American Rescue Plan increases the federal match for non-expansion populations in addition to the 90% match for the expansion population —an estimated $1.7 billion incentive to expand full Medicaid coverage in North Carolina.5 Medicaid expansion has been shown to close coverage gaps before and after pregnancy, lower maternal and infant mortality and reduce significant, persistent disparities in maternal and infant health.6 Extended postpartum coverage and Medicaid expansion increase access to necessary services and improve parent and infant health.

References:
1.Swartz JJ, Meskey J, Stuart GS, Rodriguez MI. Pregnancy Medicaid Improvements in a Nonexpansion State After the Affordable Care Act. Annals of Family Medicine. 2021 January; 19 (1) 38-40.
2. Pew Research Center, November 27, 2018, “U.S. Unauthorized Immigrant Total Dips to Lowest Level in a Decade”
3. Maternal Mortality: Trends in Pregnancy-Related Deaths and Federal Efforts to Reduce Them. Washington, DC: United States Government Accountability Office; March 2020. Publication GAO-20-248.
4. Taylor J. Promoting Better Maternal Health Outcomes by Closing the Medicaid Postpartum Coverage Gap. The Century Foundation, November 16, 2020. https://tcf.org/content/report/promoting-better-maternal-health-outcomes....
5. Rudowitz R, Carollo B, Garfield R. “New Incentive for States to Adopt the ACA Medicaid Expansion: Implications for State Spending” Kaiser Family Foundation, March 17, 2021. https://www.kff.org/medicaid/issue-brief/new-incentive-for-states-to-ado....
6. Searing A, Ross DC, “Medicaid Expansion Fills Gaps in Maternal Health Coverage Leading to Healthier Moms and Babies,” Georgetown University Health Policy Institute, May 9, 2019, https://ccf.georgetown.edu/2019/05/09/medicaid-expansion-fills-gaps-in-m....