Margerison et al. Respond to “Medicaid Policy and Reproductive Autonomy”

Expansion of Medicaid coverage under the Affordable Care Act has increased the percentage of reproductive-age women who report having health insurance by at least 9 percentage points overall, with higher increases among women without dependent children (1, 2). Yet, in our study (3), we found that expanded Medicaid eligibility during the year prior to conception was not associated with improvements in prepregnancy or pregnancy health and did not reduce the prevalence of adverse birth outcomes. These “null” findings are consistent with prior reports that expansion of Medicaid to women during pregnancy also did not reduce the prevalence of adverse birth outcomes (4, 5).

We thank Dr. Jarlenski (6) for her thoughtful comments on our article. We agree with her points regarding the ethical foundation and potential health benefits of reproductive autonomy. Accordingly, we agree that Medicaid should include policies and benefits that ensure such autonomy. We also agree that Medicaid coverage could do more to promote health over the life course, not only for women and infants but for all individuals and families. Decades of public health and policy attempts to improve pregnancy health and outcomes by focusing only on the 9 months of pregnancy have done little to reduce high rates of or disparities in preterm delivery, low birth weight, or maternal mortality in the United States. A paradigm shift within Medicaid to focus on reproductive autonomy over the life course for all individuals, regardless of sex or pregnancy status, would indeed be transformative.

However, our current findings do not necessarily suggest that Medicaid does nothing to promote reproductive autonomy. In fact, our previously published findings (7) (and those of others (8–11)) showed that the Affordable Care Act’s contraception mandate was associated with increased uptake of prescription contraceptives, particularly long-acting reversible contraceptives (8–11), but was not associated with unintended pregnancy overall (7). However, among women with government-sponsored insurance, unintended pregnancy did decrease in 2013–2015 as compared with 2008–2010 (7), indicating a potentially important role for government-sponsored health insurance (such as Medicaid) in promoting reproductive autonomy.

We also note that our finding of no association between expanded Medicaid eligibility and health outcomes may not extend to the postpartum period, as Jarlenski pointed out (6). Currently, women with Medicaid coverage during pregnancy lose eligibility 60 days postpartum unless they can requalify under income and/or parental eligibility guidelines. Yet, 11.7% of pregnancy-related deaths occur 43–365 days postpartum (12), and up to 80% of drug-related pregnancy-associated deaths occur in the second half of the postpartum year (13, 14). Extending Medicaid coverage to low-income women after pregnancy could facilitate more continuous care and offer more opportunities to identify and support women struggling with physical complications, mental health symptoms, or substance use. However, simply extending Medicaid coverage with no change in the recommendation that women attend only 1 postpartum visit at 6 weeks may be insufficient. Indeed, the American College of Obstetricians and Gynecologists recommends that postpartum care be an ongoing process rather than a single visit (15).

We share Dr. Jarlenski’s concerns about the limitations (e.g., measurement error) of available data to identify the full consequences of health insurance for preconception and pregnancy health and infant health. We also agree that health is determined only partly by interaction with the medical system as currently constituted, and that insurance thus has limited scope to affect maternal and infant health. We support Dr. Jarlenski’s point that there is a need to broaden the programmatic aspects of Medicaid or to redesign the web of poverty-related programs to address issues of systemic racism, intergenerational poverty, lack of parental leave and affordable child-care policies, unhealthy and unsafe neighborhood conditions, and other structural factors linked to poor pregnancy health and outcomes.