In this month’s Health Affairs, Daw et al examined the impact of the ACA and more specifically Medicaid expansion had on insurance churn for new mothers. They found that states that expanded Medicaid had significantly less churn and more continual coverage of mothers who had given birth:
The non-statistical version is pretty simple.
Women who lived in Medicaid Expansion states were far more likely to:
- Always be insured with the same type of insurance from conception to after birth
- Transition from Medicaid pregnancy eligibility which expires 61 days after birth to a private insurer
- Have no time being uninsured despite being insured at some point.
Why does this matter?
We have a maternal mortality crisis in the United States. American infant mortality is far higher than the infant mortality rate in peer countries. The causes behind these crisii are multi-faceted. Access to healthcare for both the mother and child is one factor. Medicaid expansion is a massive intervention targeted at individuals who, in the pre-ACA period, are highly likely to have had interruptions in coverage and when covered by private insurance, faced significant cost-sharing. Medicaid has covered pregnant women during the pre-natal period, during delivery and then for sixty days after birth. Medicaid and CHIP have generous eligibility boundaries for infants. The ACA offered two programs that could conceivably improve insurance coverage. The first is Medicaid expansion which provides low to no premium insurance with low to no cost-sharing for anyone who is income eligible up to 138% FPL. For individuals who earn over 138% FPL, the ACA offers guaranteed issue, subsidized insurance with modest premiums and limited cost sharing for individuals earning under 200% FPL. States could choose to expand or not expand Medicaid for income eligible populations. All states have ACA exchanges with varying degrees of pricing support for enrollment through either state policy or insurer strategic choices.
One of the obvious findings of this paper is that when women who had a major medical event that beat the shit out of their body, and thus medical care is a high salience item, have access to low cost and decent insurance, many women will take up that option. The logic model would be that mothers who are able to maintain some type of coverage post-partum would be likelier to access medical care and receive needed services early enough so that they are not at as high of a risk of dying. We don’t know that yet, but it is an intuitive hypothesis worth more research. Additionally, the higher level of continual enrollment in a single type of coverage probably leads to more continuity of care which has significant impacts on total cost and hopefully quality.
This is fascinating work by Dr. Daw and her team.
Makes so much sense.
“crisii”?? Should be “crises”, no? :-)
@Another Scott: I do believe you are correct.
This is so important. Thanks David.
American medical care is in so many ways a wreck, but the maternal health story is beyond enraging.
Paging pro-lifers …
I wonder if Americans care that we have the worst maternal and infant mortality in the developed world. I wonder if those rabid “pro-life” people care that so many babies die who shouldn’t. I wonder if most Americans understand that they are one Supreme Court justice’s vote away from losing their coverage for “preexisting conditions.” I wonder if Americans understand that they are said vote away from their young adult children losing their current coverage. The current attitude of all too many Americans is, “I’ve got mine; fk you.” I wonder if Americans are that selfish and stupid. I am very much afraid that all too many of them are.
Excellent news. Thank you for your reporting. It is always illuminating.
It’s reading a post like this that I find terrifying in terms of Brexit. Brexiteers are determined that we will have a US-UK trade ‘agreement’, which means that the UK will open its markets to US agricultural products that are produced with far less stringent standards than EU ones, and will open up the National Health Service to the worst ravages of the US health market. Prominent members of the current UK Cabinet are steely supporters of the privatisation of the NHS, including things like ante-natal care, drugs purchasing, etc. Already many aspects of the NHS, esp. in England, have been privatised, with a good current example of COVID contact tracing being divided between local health services and private companies like SERCO, that run things like prisons and defence contracts (and guess which track-and-trace programme is more successful …). I am in Scotland, so independence would spare us from this as we’d remain in the EU, but getting there is going to be hellish …
BoJo apparently wants to play “chicken” with Nancy SMASH. That’s a bad move.
@Another Scott: Thanks Scott!! Fingers crossed!! ;-)
@Another Scott: I just have no idea how they can do Brexit without violating the Good Friday accords. Even with a deal having an open border with an EU country would be doom for the “supposed” Brexit goals. Yet putting up a barrier would make NI explode again. That could make the ultimate solution the absorption of Northern Ireland into Ireland proper. It would take care of the Good Friday accords problem but there would be little to nothing to stop Scotland from saying “we out” also.
Hey I have something ACA related I can drop into one of these threads. Yes, I am excited.
So, perhaps you’ve heard that Joe Lieberman, the execrable prig of a former D Senator from Connecticut, endorsed Susan Collins yesterday. Well, here is a nicely detailed takedown of Lieberman based on one of the many awful things he did to the ACA when it was being legislated. I think that this happened in conjunction with AOC running against Joe Crowley in 2018 since that is mentioned.
I’ve already watched this a couple times, I think a couple more are justified. Or I could just try to find a way to inject it into my veins.
Hope everyone is having a nice day.
Excellent. Thanks for the pointer.
Maternal and infant mortality rates in the US are too high but there is also the fact that perinatal(birth to 28days of age I believe) and infant mortality is children under one year, are two separate things. Also perinatal mortality is counted differently in different countries. The US counts all live births. Some/many countries only count deaths over a certain gestational age or birth weight. Maternal mortality is too high in the US, especially for black women. Probably due to the fact that there are hugh differences in how black and white pregnant women are treated, also disparities in what care is available. Maternal mortality statistics are also a bit weird when one considers that if you die while pregnant I believe that is included in maternal mortality statistics regardless of cause of death.
CAs maternal mortality rate is 1/10th the rate of states like Georgia.
Don’t do so many unnecessary c-sections. Gonna go out on a limb and suggest the hospital billing department knows why they do so many.