Expanding Medicaid led to decreased postpartum hospitalizations

PROVIDENCE, R.I. [Brown University] — According to health care experts, the benefits for brand-new parents and their infants having access to health care during pregnancy as well as during the postpartum period are indisputable. Even so, many patients — including a third of women with pregnancy coverage through Medicaid — are uninsured before or after pregnancy.
 
To better understand how access to health care and insurance impacts postpartum health, a new study examined postpartum hospitalizations in states that had expanded Medicaid as well as those that had not.
 
In the study published in January in Health Affairs, researchers found a 17% reduction in hospitalizations during the first 60 days postpartum in states that expanded Medicaid — and, looking further out, some evidence of a smaller decrease in hospitalizations between 61 days and six months postpartum.
 
Since hospitalizations are evidence of health issues that exacerbate to the point of requiring an inpatient hospital stay, the results provide evidence that Medicaid expansion is beneficial for the health of those who have just given birth, said study co-author Maria Steenland, an assistant professor of health services, policy and practice (research) at Brown University.
 
“Our findings indicate that expanding Medicaid coverage led to improved postpartum health for low-income birthing people,” Steenland said.
 
Medicaid provides health insurance for qualifying low-income Americans. In states that adopted the Affordable Care Act Medicaid expansions since 2014, new eligibility rules allowed a larger share of low-income adults to qualify for Medicaid coverage both before pregnancy and after a 60-day postpartum period. This led to significant increases in Medicaid enrollment and overall insurance coverage both before and after pregnancy, as well as greater continuity of insurance coverage among low-income parents, Steenland explained.
 
Previous research had examined the effect of Medicaid expansion on postpartum health insurance. But there’s less information available on how the Medicaid expansion affects the use of health services during and after pregnancy — like whether, when and why new parents go to the doctor after giving birth.
 
Even prior to the ACA expansions, patients who had access to Medicaid during pregnancy were able to keep their health care coverage for 60 days after giving birth. However, without the expansion, Medicaid coverage ended at that point. The new study examined whether expanding Medicaid to cover people during pregnancy and after the 60-day postpartum cutoff period affected their rates of inpatient hospitalization.

The research, conducted by Steenland and Laura Wherry, an assistant professor of economics and public service at New York University, is the first to look at postpartum hospitalization under the ACA Medicaid expansion — “a signal of maternal health that hasn’t previously been examined,” Wherry said.
 
Compared to other high-income countries, the United States performs notably poorly on several measures of maternal health, Wherry noted: “There’s an ongoing conversation by health policy experts about the types of interventions that could improve maternal health in this country,” she said. “Our study looks at that question in the context of expanding access to health insurance through Medicaid.”
 
Steenland was a postdoctoral fellow at Brown when she first connected with Wherry, who studies the changing role of the Medicaid program and its impact on access to health care and health. The new analysis, which is part of an ongoing collaboration between the two scholars, took advantage of underused longitudinal hospital data from the period from 2010 to 2017 to examine hospitalizations after childbirth.

The researchers compared changes in hospitalizations among low-income patients with a Medicaid-financed delivery in states that did and did not expand Medicaid under the ACA, for six months after giving birth. The four expansion states included Iowa, Maryland, New Mexico and Washington; the four non-expansion states were Florida, Georgia, Mississippi and Utah. The data came from the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project State Inpatient Databases.
 
In their analysis, the researchers found similar trends in postpartum hospitalizations among new parents in the two groups of states before the ACA Medicaid expansions.
 
Starting at the time of Medicaid expansion, the relative trend in hospitalizations within 60 days postpartum decreased in expansion states compared with non-expansion states. The researchers found a 17% reduction in hospitalizations during the first 60 days postpartum associated with the Medicaid expansions. Approximately 75% of this decline can be attributed to a decrease in childbirth-related hospitalizations.

They found some evidence of a decrease in postpartum hospitalizations after 60 days. However, Wherry explained, because hospitalizations during this time period tend to be rare, the sample size was too small to draw conclusions.  

“We already know from previous studies that Medicaid expansion increased postpartum health insurance,” Steenland said. “This work is our attempt to add to this literature by looking at a potential health outcome of these changes in health insurance coverage.”
 
The study design allowed the researchers to identify a causal effect of the policy, Wherry said. 

“The 17% drop in the occurrence of 60-day postpartum hospitalizations as a result of Medicaid expansion is a meaningful decrease,” she said.
 
The policy landscape is constantly changing, Steenland said, and there is political momentum to extend Medicaid pregnancy coverage past the 60 days through the first year.
 
The researchers said that moving forward, they are interested in examining how state policies extending Medicaid pregnancy coverage through the first year after giving birth will impact not only a person’s health, but also other aspects of their lives, including their mental health and financial status.

Funding for this study was provided in part by the National Institute of Child Health and Human Development (P2C HD041020) and the Robert Wood Johnson Foundation’s Policies for Action program.