Perinatal Health Insurance And Health Care Use By Immigration Status In 6 US States, 2020–22

Abstract

Some noncitizens in the United States are not eligible for public health insurance, potentially reducing access to preconception, prenatal, and postpartum care. We compared insurance coverage and health care use from the preconception to the postpartum period by immigration status, using representative survey data collected from six US states between 2020 and 2022. Respondents were surveyed at two to six months postpartum and at twelve to fourteen months postpartum. Immigration status was classified as: 1) US citizen, 2) permanent resident, and 3) persons who were neither permanent residents nor citizens. Compared with US citizens, fewer permanent residents had late postpartum insurance coverage, but coverage rates were otherwise similar. Coverage was lower among nonpermanent residents and noncitizens compared with US citizens at every point except pregnancy, with the largest differences at preconception (90.5 percent and 50.5 percent, respectively) and late postpartum (95.1 percent and 53.2 percent, respectively). Fewer permanent residents had health care visits before pregnancy compared with US citizens, but health care use was otherwise similar. Nonpermanent residents and noncitizens had substantially lower rates of preconception health care, early and adequate prenatal care, postpartum visits, and having a usual source of care at one year postpartum. Public insurance expansions to immigrants are needed to reduce large inequities in perinatal health insurance and health care use by immigration status.

In 2021, births to immigrants represented one in every four births in the United States.¹ Timely access to high-quality preconception, prenatal, and postpartum care is important for supporting maternal-child health for immigrants.^2,3 Yet noncitizens are significantly less likely to access recommended perinatal care services and postpartum care.^4–7

A wide range of social, policy, and economic factors drive low rates of perinatal health care use among noncitizens. Lack of insurance coverage is one major barrier. In 2023, half of undocumented and 18 percent of lawfully present adult immigrants were uninsured compared with only 8 percent of US-born citizens.⁸ Relative to US citizens, noncitizens are more likely to be employed in sectors such as construction and agriculture, which often do not provide private health insurance.⁹ Undocumented immigrants are further ineligible to purchase Marketplace coverage.⁸ In terms of public coverage, Medicaid eligibility for undocumented immigrants and lawful permanent residents with fewer than five years of lawful permanent resident status (often called “nonqualified immigrants”) is extremely limited outside of pregnancy.¹⁰

Some public insurance coverage options exist for nonqualified pregnant people. In all states, nonqualified immigrants who would otherwise qualify for Medicaid have access to emergency Medicaid. However, this covers only childbirth hospitalization costs and not prenatal or postpartum care. As of May 2024, thirtystates and Washington, D.C., have adopted a policy to waive the five-year Medicaid waiting period for pregnant permanent residents, providing this group with coverage throughout pregnancy and the first sixty days postpartum.¹¹ Twenty three states also covered all low-income pregnant immigrants (including the undocumented) under from-conception-to-end-of-pregnancy policy, which was previously referred to as the unborn child option. However, this policy does not always cover postpartum care.¹² These exceptions for pregnant nonqualified immigrants, although important, are not offered in all states and do not address access to insurance preconception and in the postpartum period beyond sixty days. Further, both undocumented and permanent residents might not enroll even when eligible because of concerns about immigration-related consequences of public program enrollment, which have been exacerbated since the Trump-era public charge law.¹³

In addition to insurance-related barriers, noncitizens face a range of other barriers to health care use. Immigration enforcement can deter undocumented immigrants from using health care, and immigrants report experiencing discrimination in health care settings.^14,15 Lack of access to culturally competent care and translation services may also limit immigrants’ health care use.¹⁵

These exclusionary policies and structural health system barriers likely drive inequities in perinatal insurance coverage and health care for citizens, lawful permanent residents, and immigrants with other statuses, including the undocumented. However, because of limitations in available data on immigration status for pregnant people, scant research has documented these inequities, particularly in the preconception and postpartum periods. Neither maternal place of birth (that is, nativity) nor more detailed categories of immigration status are tracked in the Centers for Disease Control and Prevention’s (CDC’s) Pregnancy Risk Assessment Monitoring System (PRAMS), the main data source available for examining perinatal insurance coverage and outcomes in the US. Birth certificate data include maternal place of birth but do not include more detailed categories of citizenship status that correspond to Medicaid eligibility, nor do they include measures of preconception or postpartum insurance or care. Some studies of PRAMS data have used Hispanic ethnicity and language to identify likely immigrants,^16–19 but this excludes non-Hispanic immigrants and fails to differentiate immigrants by citizenship status. To address this gap, we used novel representative survey data from six states to compare perinatal insurance coverage and health care use from preconception through approximately one year postpartum between US citizens, permanent residents, and people without citizenship or permanent resident status. We also compare the prevalence of common postpartum health conditions.

Study Data And Methods

Study Population

This study used data from the 2020 PRAMS and the Postpartum Assessment of Health Survey (PAHS), a multistate survey that followed-up with PRAMS respondents twelve to fourteen months after they had a live birth in six states (Kansas, Michigan, New Jersey, Pennsylvania, Virginia, and Utah). PRAMS is the largest survey of birthing people in the US, which collects rich data on pregnancy risk factors and outcomes. PRAMS is coordinated by the CDC and is implemented by state and city departments of health. The PAHS follow-up survey was a collaboration between Columbia University and seven participating study sites. Participating sites were selected on the basis of having a sufficient PRAMS sample size (at least 1,500 respondents based on PRAMS 2019), consistently meeting the CDC PRAMS response rate thresholds, and willingness and capacity to participate. Although New York City was part of the PAHS sample, this site is excluded from this study, as it did not include a question on immigration status. The PAHS collected data on respondent’s physical and mental health, health care use, and the social determinants of health in the year after giving birth.

The 2020 PRAMS sampling frame comprised a stratified random sample of live births that occurred in 2020, drawn monthly from birth certificate records in each jurisdiction.²⁰ After applying PRAMS survey weights, which account for the sampling design and nonresponse, PRAMS is representative of live births in 2020 in the participating jurisdictions. Birthing persons in the PRAMS sampling frame were contacted by mail or telephone to complete the PRAMS survey from two to six months after birth (median response, four months postpartum). Across the six study states, the overall unweighted PRAMS response rate was 59.3 percent in 2020, which was similar to the response rate in these states in 2019 (59.4 percent) (data not shown).

The PAHS sampling frame comprised PRAMS respondents who opted-in (Michigan only; 21 percent of PRAMS respondents) or did not opt-out (the other five states; 81 percent of PRAMS respondents) of being recontacted one year after their live birth. From January 2021 to March 2022, people in the PAHS sampling frame were contacted in monthly batches by mail, telephone, and email, with weekly follow-up from twelve to fourteen months after giving birth. Of those contacted for PAHS, the response rate was 76.4 percent. Individual PAHS responses were linked to PRAMS responses and birth certificate variables. All the study states except Michigan offered PRAMS in English and Spanish in 2020, and PAHS was offered in both English and Spanish in all study states. Additional description of the PAHS survey is available elsewhere.²¹ This study was approved by the Columbia University Institutional Review Board.

State Policy Environment

All the study states except Kansas had adopted Medicaid expansion by January 2020. Three of the study states (New Jersey, Pennsylvania, and Virginia) waive the five-year waiting period for pregnant permanent residents, and two states (Michigan and Virginia) have adopted the from-conception-to-end-of-pregnancy option.²² Some states use state-only funding to provide health service coverage to pregnant and postpartum immigrants who do not qualify for pregnancy Medicaid because of their immigration status. However, no updated comprehensive documentation of these policies exists. None of the study states provide public insurance coverage to nonpregnant permanent residents in the five-year waiting period, or to undocumented immigrants.

Exposure And Demographic Variables

The primary exposure was immigration status based on respondent self-report in PAHS, with the following response options: US citizen (including naturalized immigrants), permanent resident or green card holder, and neither or other. The neither or other category (hereafter “nonpermanent residents and noncitizens”) comprises people without documentation, temporary lawful residents, and persons with temporary nonimmigrant visas (for example, students).²³ These categories correspond to Medicaid eligibility. Permanent residents in the five-year waiting period and the nonpermanent resident and noncitizen group are not eligible for Medicaid outside of pregnancy and the first sixty days postpartum in any state. Their eligibility for Medicaid during pregnancy and the postpartum period varies by state—however, permanent residents generally have more coverage options, as they can obtain Medicaid coverage after the five-year waiting period and are eligible for Marketplace coverage. We examined the following demographic characteristics reported in PAHS in each immigration group: age, race and ethnicity, marital status, education, primary language, and household income measured as a percentage of the federal poverty level.

Outcomes

Online appendix table 1 contains a detailed description of the data sources (PAHS, PRAMS, or birth certificate) and response options for all study variables.²⁴ The first study outcome was self-reported insurance coverage, measured at five points in time: preconception (the month before pregnancy), pregnancy (primary payer for prenatal care), childbirth (primary payer for delivery), early postpartum (approximately four months after childbirth), and late postpartum (twelve to fourteen months postpartum).

The second set of outcomes measured recommended health care use and access before, during, and after pregnancy. Preconception care measured self-reported health care visits with a doctor, nurse, or other health care worker during the twelve months before becoming pregnant. Early prenatal care measured first prenatal care visit during the first trimester of pregnancy. Adequate prenatal care measured whether the respondent initiated prenatal care in the first four months of pregnancy and completed 80 percent of expected visits. Early postpartum care measured self-reported receipt of a postpartum check-up at four to six weeks postpartum. Late postpartum care measured whether the respondent reported having a usual source of health care at twelve to fourteen months postpartum.

To document postpartum health care needs, we leveraged a novel series of questions on self-reported postpartum health issues that do not require clinical diagnosis. Mental health measures included depression (that is, a score of >3 on the Patient Health Questionnaire-2, indicating a probable diagnosis of major depressive disorder) and anxiety (that is, a score of >3 on the Generalized Anxiety Disorder two-item screening instrument, indicating a probable diagnosis of generalized anxiety disorder) at twelve to fourteen months postpartum. Physical health measures included reported experience of the following common postpartum symptoms since childbirth: pelvic hip or back pain; breast problems, infections, or pain; sexual dysfunction, pain, or other issues; and urinary problems, infections, or incontinence.

Statistical Analysis

We calculated survey-weighted rates and 95% confidence intervals for each outcome stratified by immigration status to produce estimates that are representative of live births in the included states. To compare rates between groups, we used unadjusted survey-weighted logistic regression to estimate marginal differences in the outcomes relative to US citizens, measured in percentage points. We did not conduct any adjusted analyses because we were interested in documenting differences between groups irrespective of the underlying factor or factors driving the difference. Because Medicaid eligibility restrictions would only affect insurance for lower-income respondents, we also conducted the analysis of insurance coverage outcomes among respondents with income below 200 percent of the federal poverty level, which is the median income eligibility level for pregnancy Medicaid in the US.

Our analysis used PAHS survey weights, which build on the CDC PRAMS analytic weights to additionally account for nonresponse to PAHS. Missingness ranged from 0 percent to 4.4 percent for the insurance outcomes, and from 0.8 percent to 2.4 percent for the health care use outcomes. Less than 1 percent of observations were missing data for all the postpartum health condition outcomes (Appendix table 2). The percentage missing in the study outcomes was very similar across the immigration status groups (appendix table 2).²⁴ To retain as much data as possible for the analysis, we conducted complete case analysis for each outcome. Analyses were conducted using Stata, version 17.

Limitations

This study has several limitations. This study included only six states and might not be generalizable to states that are not included in this analysis. In particular, differences in insurance status may be attenuated in states that have not expanded Medicaid, in which preconception and postpartum uninsurance in the overall population is higher relative to that in states with Medicaid expansion. Because our study sample gave birth in 2020, pandemic-related employment and health care disruptions may have affected our results. Importantly, during the public health emergency, people with Medicaid pregnancy-related coverage retained that coverage beyond the previous sixty-day cutoff, which may have increased early and late postpartum insurance relative to previous years.^25,26 However, our findings are highly relevant to the postpandemic context, in which nearly all states (forty-seven states including Washington, D.C.) have since implemented a permanent twelve-month postpartum extension of pregnancy Medicaid.²⁷ In addition, the small number of states in this study prevented us from examining the association between state policies and the study outcomes.

In addition, PRAMS and PAHS were only conducted in English and Spanish, which may have limited inclusion of immigrants without English or Spanish language proficiency. However, PAHS respondents reported more than twenty different primary languages. To encourage response, the PAHS citizenship question included an “other” category, rather than asking noncitizen and nonpermanent resident respondents to reveal their specific visa or documentation status. Although this question had low levels of missingness (2.4 percent; data not shown), noncitizen and nonpermanent resident status may still be underreported. Further, the nonpermanent resident and noncitizen group included both undocumented people and other immigrant groups who qualify for Medicaid (for example, refugees). We expect that most of this group was undocumented, as nationally, 85 percent of nonpermanent resident and noncitizens are undocumented.²³ The study’s data set did not include a variable measuring country of birth, or sufficient sample size to further refine our noncitizen subgroups by length of time in the US, which is associated with birth outcomes.^28,29 We measured postpartum symptoms, but we do not know whether participants received a diagnosis from a medical provider. Finally, because of the study’s small sample size, we were not able to conduct subgroup analysis by factors such as insurance type at childbirth.

Study Results

The study sample included 3,859 postpartum respondents, including 3,449 US citizens (89.4 percent), 187 permanent residents (4.8 percent), and 223 nonpermanent resident and noncitizens (5.8 percent). The age distribution was similar between the three groups (exhibit 1). The majority of citizens reported non-Hispanic White race and ethnicity (67.5 percent), whereas the plurality of permanent residents and nonpermanent residents and noncitizens identified as Hispanic (39.1 percent and 68.8 percent, respectively).

Exhibit 1:

Sample characteristics of postpartum people in six states, overall and by immigration status, 2020

Characteristics	Overall (N = 3,859), %	Citizens (N = 3,449)	Permanent residents (N = 187	Non–permanent residents and noncitizens (N = 223)
Age, years (%)
18–24	20.2	19.7	22.0	24.6
25–29	27.3	27.2	25.4	30.7
30–34	32.1	33.3	28.0	20.6
35+	20.4	19.8	24.6	24.2
Race and ethnicity (%)
Non-Hispanic White	59.9	67.5	17.6	1.1
Non-Hispanic Black	14.7	15.6	13.6	5.3
Hispanic or Latinx	15.1	9.2	39.1	68.8
Asian, Asian-American, NHPI, or SWMENA	8.4	5.6	29.6	24.8
Native American or Alaskan Native	0.9	1.0	0.0	0.0
Multiple minority races	1.0	1.1	0.1	0.0
Marital status (%)
Not married or no domestic partner	21.8	22.0	13.8	24.8
Married or domestic partner	78.2	78.0	86.2	75.2
Education (%)
Less than high school	8.3	6.8	11.8	24.7
High school	21.4	20.4	25.1	30.7
More than high school	70.3	72.8	63.1	44.7
Primary language (%)
English	87.1	95.7	41.1	17.0
Spanish	7.3	1.7	28.5	60.1
Other	5.6	2.6	30.4	22.9
Years in the US	—a	—a	9.9	6.9
Household income, % of FPL (%)
≤138%	36.3	32.8	53.2	70.9
139–199%	9.6	9.8	11.1	5.9
200–399%	31.1	33.7	14.8	10.5
400%+	22.9	23.8	20.9	12.7
Missing	2.2	1.3	6.4	12.6

SOURCE Authors’ analysis of data from the 2020 Pregnancy Risk Assessment Monitoring System (PRAMS) and the Postpartum Assessment of Health Survey (PAHS). NOTES Sample included postpartum people who had a live birth in 2020 in six states (Kansas, Michigan, New Jersey, Pennsylvania, Utah, and Virginia) who were included in the PRAMS survey at 2–6 months postpartum and who participated in the PAHS survey at 12–14 months postpartum. Missing statistics for variables with less than 1 percent missing are not shown. PR is permanent resident. NHPI is Native Hawaiian or Pacific Islander. SWMENA is Southwest Asian, Middle Eastern, or North African. FPL is federal poverty level.

^aNot applicable.

Approximately 78 percent of respondents were married, with similar percentages by immigration status. Fewer permanent residents and nonpermanent residents and noncitizens had greater than a high school education, relative to citizens (63.1 percent, 44.7 percent, and 72.8 percent, respectively). The primary language of most citizens was English (95.7 percent), whereas English was the primary language of only 41.1 percent of permanent residents and 17.0 percent of nonpermanent residents and noncitizens. Relative to citizens, permanent residents and nonpermanent residents and noncitizens were more likely to have a household income below 138 percent of poverty, which is the threshold for adult and parental Medicaid eligibility in most states (32.8 percent, 53.2 percent and 70.9 percent, respectively).

Among citizens, insurance coverage rates ranged from a low of 90.5 percent preconception to a high of 98.4 percent at childbirth (exhibit 2, appendix table 3).²⁴ Among permanent residents, insurance coverage was lower at preconception (82.3 percent) and in the late postpartum period (86.6 percent) than during pregnancy (93.0 percent), at childbirth (92.3 percent), and during the early postpartum period (89.8 percent). Compared with citizens, insurance coverage among permanent residents in the late postpartum period was 8.4 percentage points lower (95.1 percent versus 86.6 percent; p = 0.03), but differences at other points were not significant. Among nonpermanent residents and noncitizens, only approximately half (50.5 percent) had preconception insurance coverage. Insurance coverage was greater in this group during pregnancy (92.5 percent) and at birth (84.9 percent), but decreased substantially in the early (68.4 percent) and late (53.2 percent) postpartum periods. Compared with citizens, insurance coverage among nonpermanent residents and noncitizens was similar during pregnancy, but 40.1 percentage points lower at preconception (90.5 percent versus 50.5 percent; p < 0.001), 13.5 percentage points lower at childbirth (98.4 percent versus 84.9 percent; p < 0.001), 25.8 percentage points lower at early postpartum (94.2 percent versus 68.4 percent; p < 0.001) and 41.9 percentage points lower at late postpartum (95.1 percent versus 53.2 percent; p < 0.001) (exhibit 2, appendix table 3).²⁴ Differences in coverage between nonpermanent residents and noncitizens and citizens were similar in the subgroup of respondents with low income (appendix table 4).²⁴

Exhibit 2.

Peripartum insurance coverage among respondents in six states, by immigration status, 2020

Source/Notes: SOURCE Authors’ analysis of data from the 2020 Pregnancy Risk Assessment Monitoring System (PRAMS) and the Postpartum Assessment of Health Survey (PAHS). NOTES Sample included postpartum people who had a live birth in 2020 in six states (Kansas, Michigan, New Jersey, Pennsylvania, Utah, and Virginia), who were included in the PRAMS survey at 2–6 months postpartum, and who participated in the PAHS survey at 12–14 months postpartum. US citizens were used as the reference group for statistical comparisons. Vertical bars represent 95% confidence intervals. PR is permanent resident. *p < 0.1 **p < 0.05 ****p < 0.001

Compared with US citizens, preconception health care use among permanent residents was 12.0 percentage points lower (60.5 percent compared with 72.5 percent; p = 0.02). Only 40.2 percent of nonpermanent residents and noncitizens reported preconception health care, which was 32.3 percentage points lower than citizens (p < 0.001) (exhibit 3, appendix table 3).²⁴ The percentage of respondents with early prenatal care was similar among citizens and permanent residents (87.4 percent and 82.1 percent, respectively; p = 0.10), but was 21.0 percentage points lower among nonpermanent residents and noncitizens, relative to citizens (66.3 percent; p < 0.001). The rate of adequate prenatal care was similar between citizens (75.9 percent) and permanent residents (70.0 percent; p = 0.26), but was 8.8 percentage points lower among nonpermanent residents and noncitizens relative to citizens (67.1 percent; p = 0.04). Citizens and permanent residents had the same rate of having attended the 4–6-week postpartum visit (87.1 percent in both groups), but postpartum visit attendance was 13.0 percentage points lower among nonpermanent residents and noncitizens, relative to citizens (87.1 percent and 74.2 percent, respectively; p < 0.001). Having a usual source of late postpartum care was similar among citizens (72.2 percent) and permanent residents (61.9 percent; p = 0.10), but was 13.8 percentage points lower among nonpermanent residents and noncitizens compared with citizens (58.4 percent; p = 0.03).

Exhibit 3.

Peripartum health care use among respondents in six states, by immigration status, 2020

Source/Notes: SOURCE Authors’ analysis of data from the 2020 Pregnancy Risk Assessment Monitoring System (PRAMS) and the Postpartum Assessment of Health Survey (PAHS). NOTES Sample included postpartum people who had a live birth in 2020 in six states (Kansas, Michigan, New Jersey, Pennsylvania, Utah, and Virginia), who were included in the PRAMS survey at 2–6 months postpartum, and who participated in the PAHS survey at 12–14 months postpartum. US citizens were used as the reference group for statistical comparisons. Vertical bars represent 95% confidence intervals. PR is permanent resident. **p < 0.05 ****p < 0.001

Postpartum anxiety rates were similar among citizens (14.4 percent) and permanent residents (10.1 percent; p = 0.19) (exhibit 4, appendix table 3).²⁴ Anxiety rates were 8.9 percentage points lower among nonpermanent residents and noncitizens, relative to citizens (5.5 percent and 14.4 percent, respectively; p < 0.001). Postpartum depression rates were similar and not statistically different in the three study groups (8.8 percent, 15.6 percent, and 7.8 percent among citizens, permanent residents, and nonpermanent residents and noncitizens, respectively; p > 0.05). Rates of pelvic, hip, or back pain were similar among citizens (28.2 percent) and permanent residents (30.8 percent; p = 0.61), but were 15.2 percentage points greater among nonpermanent residents and noncitizens compared with citizens (43.3 percent; p < 0.001). Rates of sexual dysfunction, pain, or other issues were similar among citizens (14.4 percent) and permanent residents (11.7 percent; p = 0.41), but were 8.4 percentage points lower among nonpermanent residents and noncitizens compared with citizens (6.0 percent; p = 0.01). Differences between groups in the rate of breast problems, infections, or pain and the rate of urinary problems, infections, incontinence, or other issues were not statistically significant (exhibit 4, appendix table 3).²⁴

Exhibit 4.

Postpartum health issues among respondents in six states, by immigration status, 2020

Source/Notes: SOURCE Authors’ analysis of data from the 2020 Pregnancy Risk Assessment Monitoring System (PRAMS) and the Postpartum Assessment of Health Survey (PAHS). NOTES Sample included postpartum people who had a live birth in 2020 in six states (Kansas, Michigan, New Jersey, Pennsylvania, Utah, and Virginia), who were included in the PRAMS survey at 2–6 months postpartum, and who participated in the PAHS survey at 12–14 months postpartum. US citizens were used as the reference group for statistical comparisons. Vertical bars represent 95% confidence intervals. PR is permanent resident. **p < 0.05 ****p < 0.001

Discussion

Using novel representative multistate survey data in six states, we found large differences in health insurance coverage and recommended health care use from preconception through to one year postpartum by immigration status. Rates of insurance were at least 90 percent for citizens and at least 80 percent for permanent residents during every time point measured from preconception to the late postpartum period. Although the vast majority of nonpermanent residents and noncitizens had insurance during pregnancy, almost half were uninsured before pregnancy, and insurance rates dropped to 53 percent by one year postpartum. Compared with citizens, nonpermanent residents and noncitizens were also significantly less likely to have preconception health care, early prenatal care, a routine postpartum visit, and a usual source of care approximately one year after childbirth.

We found that more than one in ten nonpermanent residents and noncitizens experienced pain, breast-related health issues, and urinary-related health issues, suggesting that noncitizens without access to health care after childbirth may face unmet health care needs. These unmet needs may lead to more severe adverse health outcomes, as mastitis and urinary infections are among the most common causes of postpartum readmissions.³⁰

We found that differences in insurance coverage and health care use by immigration status were widest before pregnancy and during the postpartum periods. These periods correspond to times when public insurance coverage options for nonpermanent residents and noncitizens do not exist in the study states and are extremely rare throughout the US. As 71 percent of nonpermanent residents and noncitizens in our study had income below the threshold for Medicaid eligibility as an adult or parent, limited public insurance access before and after pregnancy may play a role in driving these disparities. However, this study is not designed to causally identify a relationship between insurance coverage and health care receipt.

Differences in insurance coverage and health care use between the study groups are also likely to be driven by discrimination, language barriers and cultural barriers, and fear that public service use could affect immigration decisions. Nonetheless, increasing access to health insurance is a promising policy solution to decrease the health care disparities documented in this study. Previous public insurance expansions to undocumented and recent immigrants increased prenatal care, postpartum care, and postpartum contraception.^31–34 Recent state expansions of public insurance coverage to some adult age groups suggest that state-level policy can provide a path to increased insurance access for immigrants. In addition, two states (Colorado and Washington) are using private insurance options to expand insurance to nonqualified immigrants.

In addition, current state policy decisions have the potential to reduce disparities in postpartum insurance between US citizens and nonpermanent residents and noncitizens. The American Rescue Plan Act of 2021 gave states the option to extend postpartum Medicaid coverage from sixty days through twelve months.²⁷ Ten of the forty-six states that have implemented twelve-month pregnancy Medicaid extensions (California, Connecticut, Illinois, Maine, Massachusetts, Minnesota, New York, Oregon, Rhode Island, and Washington) have extended postpartum coverage regardless of immigration status.⁸ States can use state funds or federal funding from the Children’s Health Insurance Program Health Services Initiative to provide twelve months of postpartum coverage to all income-eligible immigrants who do not qualify for Medicaid.³⁵

Federal policy, including executive action, can also affect health insurance coverage and health care use among immigrants before, during, and after pregnancy. The changes to the public charge rule under the Trump administration were associated with delayed prenatal care initiation among uninsured immigrants and increased preterm birth among Hispanic immigrants.³⁶ In September 2022, the Biden administration restored the “public charge” rule to its interpretation from before the Trump administration, clarifying that going forward, receipt of Medicaid benefits would not adversely affect applications for permanent residence status.¹³

Conclusion

There are large inequities in perinatal health insurance and health care use by immigration status. Public insurance expansions to immigrants are a promising policy option to reduce large inequities in these outcomes.