Insuring Women in the United States Before, During, and After Pregnancies

The US health care system has historically put women of reproductive age at risk for being uninsured before their first pregnancy and during interconception periods. This is especially true for low-income women because of historical categorical eligibility requirements for the Medicaid program, which brought many women into the program only at pregnancy and dropped their coverage 60 days postpartum. While the Medicaid program now pays for almost half of all births in the United States,¹ the use of categorical requirements rather than poverty alone helped lead to inconsistent and lacking health insurance coverage for women.

In recognition of the nation’s eroding progress on maternal and infant outcomes, our Governors encouraged the expansion of Medicaid to pregnant women, infants, and children during the 1980s. While these expansions brought more women into Medicaid and were generally found to increase early prenatal care, the evidence on improved birth outcomes was quite limited.² This may be attributable in part to the unstable nature of the health insurance coverage that the expansions brought to women. The failure of Medicaid and other public programs to fully address the needs of women of reproductive age underlies the fact that the United States ranked 26th among Organisation for Economic Co-operation and Development nations on infant mortality in 2010.³ Moreover, outcomes vary within the United States, with disproportionately high infant mortality among southeastern states, minority groups, and families with low socioeconomic status.

INSURANCE COVERAGE OF NEW MOTHERS

The Pregnancy Risk Assessment Monitoring System (PRAMS) is a surveillance project administered through the Centers for Disease Control and Prevention (CDC) in cooperation with participating states’ health departments.⁴ It is the only data source on insurance coverage of new mothers before, during, and at delivery. Currently, 40 states and New York City participate in the PRAMS and data are available to researchers through a CDC proposal review process or directly from participating states.

A recent MMWR summary^5,6 used PRAMS data to document that approximately one third of new mothers experienced transitions in insurance coverage during pregnancy. Among those experiencing transitions, almost three quarters were uninsured just prior to pregnancy while more than two thirds were covered by Medicaid at delivery. Young, minority, less-educated, single, and low-income mothers were particularly at risk for unstable coverage. It is important to note that the level and patterns of unstable coverage documented in this analysis have not changed since the latter-1990s when the PRAMS data were used to report very similar findings.⁷ Thus, despite a number of factors influencing birth rates and insurance over the past 15 years (1999–2009), including Medicaid eligibility expansions, a significant number of new mothers remained uninsured before pregnancy in 2009. Moreover, a large percentage of women uninsured before pregnancy still transitioned to Medicaid for delivery as they had in the latter-1990s. Thus, Medicaid still served as their insurance safety net, but for many this coverage likely began late in their pregnancy.

PUBLIC POLICIES

The Affordable Care Act (ACA; Pub L No. 111–148) provides new opportunities for coverage of women of reproductive age by expanding access to health insurance nationally and improving the quality of care covered by that insurance. In particular, women under 138% of the federal poverty level will be eligible for Medicaid independent of their pregnancy status if they reside in states that expand Medicaid. Subsidization of private policies, which must now include all family planning and preventive care services without copayments, will be available to women at 100% to 400% of the federal poverty level who are not otherwise eligible for Medicaid. Gaps will remain, however, because of the refusal of 19 states to expand Medicaid as of January 2016. In nonexpanding states, an estimated 1.7 million women will not be eligible for either Medicaid or subsidized private policies and will still face unstable coverage during a pregnancy.⁸

PRAMS DATA

The PRAMS is a critically important data source for future monitoring on this issue because of its unique questions regarding insurance coverage. The PRAMS has also recently updated insurance questions to better distinguish between public and private coverage. Most importantly, the PRAMS added a question measuring insurance coverage following delivery. The power of the PRAMS also derives from its state-representativeness of live births and the ability to link PRAMS observations to their vital records. Additionally, data on sociodemographic and maternal risk factors, stressors, family size, and income only add to its power. The PRAMS is threatened by significant lags in the availability of data and by inconsistent state participation over time. A new collection system implemented in 2012 to 2013 should help shorten the lags. Yet, many states, especially those in the southeast where birth outcomes remain poor, lack sufficient response rates to allow for public reporting of the 2012 survey. The ACA provides opportunities to improve coverage in ways that have not happened over the past 15 years through Medicaid expansion and federal subsidies on the Marketplace. During this time of policy change, it is critically important for the nation to have access to data collected through the PRAMS so that analysis of the effects of these policies can continue.

CONCLUSIONS

The nation continues to acknowledge insurance coverage for women of reproductive age and mothers as a key public health issue. While patterns of coverage for new mothers have not changed from 1999 to 2009, the ACA offers the potential for consistent, reliable coverage for women of reproductive years across the periods of preconception, during pregnancy, and after delivery. Mothers and infants are a priority population, and continued state-level data collection and reporting is paramount to monitor progress toward improved coverage and health outcomes. To this end, the PRAMS should be kept on a sustainable funding trajectory, supported by federal funding to overcome challenges stemming from state budgetary concerns and political stances regarding the ACA. Continued funding and support of the PRAMS is necessary for the evaluation of the impacts of the ACA not only on patterns of health insurance coverage for women of reproductive age, but also on potential improvements in maternal and infant outcomes.