Association of the United States Affordable Care Act Dependent Coverage Provision with Labor Neuraxial Analgesia Use.

BACKGROUND: Providing continuous health insurance coverage during the perinatal period may increase access to and utilization of labor neuraxial analgesia. This study tested the hypothesis that implementation of the 2010 Dependent Coverage Provision of the Patient Protection and Affordable Care Act, requiring private health insurers to allow young adults to remain on their parent's plan until age 26 yr, was associated with increased labor neuraxial analgesia use. METHODS: This study used a natural experiment design and birth certificate data for spontaneous vaginal deliveries in 28 U.S. states between 2009 and 2013. The intervention was the Dependent Coverage Provision, categorized into pre- and postintervention periods (January 2009 to August 2010 and September 2010 to December 2013, respectively). The exposure was women's age, categorized as exposed (21 to 25 yr) and unexposed (27 to 31 yr). The outcome was the labor neuraxial analgesia utilization rate. RESULTS: Of the 4,515,667 birth certificates analyzed, 3,033,129 (67.2%) indicated labor neuraxial analgesia use. For women aged 21 to 25 yr, labor neuraxial analgesia utilization rates were 64.9% during the preintervention period and 68.9% during the postintervention period (difference, 4.0%; 95% CI, 3.9 to 4.2). For women aged 27 to 31 yr, labor neuraxial analgesia utilization rates were 64.9% during the preintervention period and 67.7% during the postintervention period (difference, 2.8%; 95% CI, 2.7 to 2.9). After adjustment, implementation of the Dependent Coverage Provision was associated with a 1.0% (95% CI, 0.8 to 1.2) absolute increase in labor neuraxial analgesia utilization rate among women aged 21 to 25 yr compared with women aged 27 to 31 yr. The increase was statistically significant for White and Hispanic women but not for Black and Other race and ethnicity women. CONCLUSIONS: Implementation of the Dependent Coverage Provision was associated with a statistically significant increase in labor neuraxial analgesia use, but the small effect size is unlikely of clinical significance.

Using Modernized Medicaid Data to Advance Evidence-Based Improvements in Maternal Health.

Medicaid is the primary payor for nearly half of all births in the United States and plays a disproportionate role in covering maternity care for low-income people, rural people, and minoritized racial groups. Newly available, modernized Medicaid claims data-the Transformed Medicaid Statistical Information System Analytic Files (TAF)-offer a significant opportunity to conduct novel research that can drive the development of evidence-based programs and policies for Medicaid beneficiaries before, during, and after pregnancy. Yet, the public health research community has so far underused the TAF for maternal health research. We provide an overview of the TAF and how they compare to other major data sets available to study maternal health. We highlight some major limitations of the TAF and offer strategies to maximize the potential of these novel data to accelerate timely, rigorous research to improve maternal health and health equity. (Am J Public Health. 2023;113(7):805-810. https://doi.org/10.2105/AJPH.2023.307287).

Extending Postpartum Medicaid: State and Federal Policy Options during and after COVID-19.

The United States is facing a maternal health crisis with rising rates of maternal mortality and morbidity and stark disparities in maternal outcomes by race and socioeconomic status. Among the efforts to address this issue, one policy proposal is gaining particular traction: extending the period of Medicaid eligibility for pregnant women beyond 60 days after childbirth. The authors examine the legislative and regulatory pathways most readily available for extending postpartum Medicaid, including their relative political, economic, and public health trade-offs. They also review the state and federal policy activity to date and discuss the impact of the COVID-19 pandemic on the prospects for policy change.

The Affordable Care Act and Access to Care for Reproductive-Aged and Pregnant Women in the United States, 2010-2016.

OBJECTIVES: To estimate the association between the Affordable Care Act (ACA), health insurance coverage, and access to care among reproductive-aged and pregnant women. METHODS: We performed an observational study comparing current insurance type, cost-related barriers to medical care, and no usual source of care among reproductive-aged (n = 128 352) and pregnant (n = 2179) female respondents to the National Health Interview Survey in the United States, before (2010-2013) and after (2015-2016) the ACA coverage expansions. RESULTS: Among reproductive-aged women, the ACA was associated with a 7.4 percentage-point decrease in the probability of uninsurance (95% confidence interval [CI] = -8.6, -6.2), a 3.6 percentage-point increase in Medicaid (95% CI = 2.5, 4.7), and a 3.1 percentage-point increase in nongroup private coverage (95% CI = 2.1, 4.1). The ACA was also associated with a 1.5 percentage-point decline in cost-related barriers to medical care (95% CI = -2.6, -0.5) and a 2.4 percentage-point reduction in lacking a usual source of care (95% CI = -4.5, -0.3). We did not find significant changes in insurance or cost-related barriers to care for pregnant women. CONCLUSIONS: The ACA was associated with expanded insurance coverage and improvements in access to care for women of reproductive age, particularly for those with lower incomes.

Association of the Affordable Care Act Dependent Coverage Provision With Prenatal Care Use and Birth Outcomes.

Importance: The effect of the Affordable Care Act (ACA) dependent coverage provision on pregnancy-related health care and health outcomes is unknown. Objective: To determine whether the dependent coverage provision was associated with changes in payment for birth, prenatal care, and birth outcomes. Design, Setting, and Participants: Retrospective cohort study, using a differences-in-differences analysis of individual-level birth certificate data comparing live births among US women aged 24 to 25 years (exposure group) and women aged 27 to 28 years (control group) before (2009) and after (2011-2013) enactment of the dependent coverage provision. Results were stratified by marital status. Main Exposures: The dependent coverage provision of the ACA, which allowed young adults to stay on their parent's health insurance until age 26 years. Main Outcomes and Measures: Primary outcomes were payment source for birth, early prenatal care (first visit in first trimester), and adequate prenatal care (a first trimester visit and 80% of expected visits). Secondary outcomes were cesarean delivery, premature birth, low birth weight, and infant neonatal intensive care unit (NICU) admission. Results: The study population included 1 379 005 births among women aged 24-25 years (exposure group; 299 024 in 2009; 1 079 981 in 2011-2013), and 1 551 192 births among women aged 27-28 years (control group; 325 564 in 2009; 1 225 628 in 2011-2013). From 2011-2013, compared with 2009, private insurance payment for births increased in the exposure group (36.9% to 35.9% [difference, -1.0%]) compared with the control group (52.4% to 51.1% [difference, -1.3%]), adjusted difference-in-differences, 1.9 percentage points (95% CI, 1.6 to 2.1). Medicaid payment decreased in the exposure group (51.6% to 53.6% [difference, 2.0%]) compared with the control group (37.4% to 39.4% [difference, 1.9%]), adjusted difference-in-differences, -1.4 percentage points (95% CI, -1.7 to -1.2). Self-payment for births decreased in the exposure group (5.2% to 4.3% [difference, -0.9%]) compared with the control group (4.9% to 4.3% [difference, -0.5%]), adjusted difference-in-differences, -0.3 percentage points (95% CI, -0.4 to -0.1). Early prenatal care increased from 70% to 71.6% (difference, 1.6%) in the exposure group and from 75.7% to 76.8% (difference, 0.6%) in the control group (adjusted difference-in-differences, 0.6 percentage points [95% CI, 0.3 to 0.8]). Adequate prenatal care increased from 73.5% to 74.8% (difference, 1.3%) in the exposure group and from 77.5% to 78.8% (difference, 1.3%) in the control group (adjusted difference-in-differences, 0.4 percentage points [95% CI, 0.2 to 0.6]). Preterm birth decreased from 9.4% to 9.1% in the exposure group (difference, -0.3%) and from 9.1% to 8.9% in the control group (difference, -0.2%) (adjusted difference-in-differences, -0.2 percentage points (95% CI, -0.3 to -0.03). Overall, there were no significant changes in low birth weight, NICU admission, or cesarean delivery. In stratified analyses, changes in payment for birth, prenatal care, and preterm birth were concentrated among unmarried women. Conclusions and Relevance: In this study of nearly 3 million births among women aged 24 to 25 years vs those aged 27 to 28 years, the Affordable Care Act dependent coverage provision was associated with increased private insurance payment for birth, increased use of prenatal care, and modest reduction in preterm births, but was not associated with changes in cesarean delivery rates, low birth weight, or NICU admission.

Estimated cost of universal public coverage of prescription drugs in Canada.

BACKGROUND: With the exception of Canada, all countries with universal health insurance systems provide universal coverage of prescription drugs. Progress toward universal public drug coverage in Canada has been slow, in part because of concerns about the potential costs. We sought to estimate the cost of implementing universal public coverage of prescription drugs in Canada. METHODS: We used published data on prescribing patterns and costs by drug type, as well as source of funding (i.e., private drug plans, public drug plans and out-of-pocket expenses), in each province to estimate the cost of universal public coverage of prescription drugs from the perspectives of government, private payers and society as a whole. We estimated the cost of universal public drug coverage based on its anticipated effects on the volume of prescriptions filled, products selected and prices paid. We selected these parameters based on current policies and practices seen either in a Canadian province or in an international comparator. RESULTS: Universal public drug coverage would reduce total spending on prescription drugs in Canada by $7.3 billion (worst-case scenario $4.2 billion, best-case scenario $9.4 billion). The private sector would save $8.2 billion (worst-case scenario $6.6 billion, best-case scenario $9.6 billion), whereas costs to government would increase by about $1.0 billion (worst-case scenario $5.4 billion net increase, best-case scenario $2.9 billion net savings). Most of the projected increase in government costs would arise from a small number of drug classes. INTERPRETATION: The long-term barrier to the implementation of universal pharmacare owing to its perceived costs appears to be unjustified. Universal public drug coverage would likely yield substantial savings to the private sector with comparatively little increase in costs to government.

Framing incremental expansions to public health insurance systems: the case of Canadian pharmacare.

Canada is the only country in the world to offer universal comprehensive public health insurance that excludes outpatient prescription medicines. Few scholars have attempted to explain this policy puzzle. We study media coverage of prescription drug financing from 1990 to 2010 to elucidate how the policy problem and potential solutions have been framed in media discourse and identify the actors that have dominated media texts. We confirm previous analyses that have revealed the significant role played by policy elites in media coverage of health reform debates. We also find that proposed expansions to public coverage are presented as a financial liability that could "crowd out" the existing (and popular) public insurance program. Within the context of a predominantly public funded system, framing of incremental expansion reorients away from values and toward discourse related to costs--both of the current system and of potential reforms. This may reflect a strategic narrative used by actors to maintain "silos of values" for coverage for prescription medicines versus those for other services. This has significant implications for the motivation for reform among the electorate and politicians alike, and for the extent to which policy developments, if they occurred, would legitimately reflect societal values for health financing.

Comparing approaches to identify live births using the Transformed Medicaid Statistical Information System.

OBJECTIVE: To evaluate the performance of different approaches for identifying live births using Transformed Medicaid Statistical Information System Analytic Files (TAF). DATA SOURCES: The primary data source for this study were TAF inpatient (IP), other services (OT), and demographic and eligibility files. These data contain administrative claims for Medicaid enrollees in all 50 states and the District of Columbia from January 1, 2018 to December 31, 2018. STUDY DESIGN: We compared five approaches for identifying live birth counts obtained from the TAF IP and OT data with the Centers for Disease Control and Prevention (CDC) Natality data-the gold standard for birth counts at the state level. DATA COLLECTION/EXTRACTION METHODS: The five approaches used varying combinations of diagnosis and procedure, revenue, and place of service codes to identify live births. Approaches 1 and 2 follow guidance developed by the Centers for Medicare and Medicaid Services (CMS). Approaches 3 and 4 build on the approaches developed by CMS by including all inpatient hospital claims in the OT file and excluding codes related to delivery services for infants, respectively. Approach 5 applied Approach 4 to only the IP file. PRINCIPAL FINDINGS: Approach 4, which included all inpatient hospital claims in the OT file and excluded codes related to infants to identify deliveries, achieved the best match of birth counts relative to CDC birth record data, identifying 1,656,794 live births-a national overcount of 3.6%. Approaches 1 and 3 resulted in larger overcounts of births (20.5% and 4.5%), while Approaches 2 and 5 resulted in undercounts of births (-3.4% and -6.8%). CONCLUSIONS: Including claims from both the IP and OT files, and excluding codes unrelated to the delivery episode and those specific to services rendered to infants improves accuracy of live birth identification in the TAF data.

Childcare disruptions and maternal health during the COVID-19 pandemic.

During the COVID-19 pandemic, nearly all US states enacted stay-at-home orders, upending usual childcare arrangements and providing a unique opportunity to study the association between childcare disruptions and maternal health. Using data from the 2021-2022 National Survey of Children's Health, we estimated the association between childcare disruptions due to the COVID-19 pandemic and self-reported mental and physical health among female parents of young children (ages 0-5 years). Further, we assessed racial, ethnic, and socioeconomic disparities in (1) the prevalence of childcare disruptions due to the COVID-19 pandemic and (2) the association between childcare disruptions and mental or physical health. Female parents who experienced childcare disruptions due to the COVID-19 pandemic were less likely to report excellent or very good mental (-7.4 percentage points) or physical (-2.5 percentage points) health. Further, childcare disruptions were more common among parents with greater socioeconomic privilege (ie, higher education, higher income), but may have been more detrimental to health among parents with less socioeconomic privilege (eg, lower education, lower income, and single parents). As state and federal policymakers take action to address the maternal health crisis in the United States, our findings suggest that measures to improve childcare stability may also promote maternal health and health equity.

Continuous Medicaid Eligibility During the COVID-19 Pandemic and Postpartum Coverage, Health Care, and Outcomes.

Importance: Pursuant to the Families First Coronavirus Response Act (FFCRA), continuous Medicaid eligibility during the COVID-19 public health emergency (PHE) created a de facto national extension of pregnancy Medicaid eligibility beyond 60 days postpartum. Objective: To evaluate the association of continuous Medicaid eligibility with postpartum health insurance, health care use, breastfeeding, and depressive symptoms. Design, Setting, and Participants: This cohort study using a generalized difference-in-differences design included 21 states with continuous prepolicy (2017-2019) and postpolicy (2020-2021) participation in the Pregnancy Risk Assessment Monitoring System (PRAMS). Exposures: State-level change in Medicaid income eligibility after 60 days postpartum associated with the FFCRA measured as a percent of the federal poverty level (FPL; ie, the difference in 2020 income eligibility thresholds for pregnant people and low-income adults/parents). Main Outcomes and Measures: Health insurance, postpartum visit attendance, contraceptive use (any effective method; long-acting reversible contraceptives), any breastfeeding and depressive symptoms at the time of the PRAMS survey (mean [SD], 4 [1.3] months postpartum). Results: The sample included 47 716 PRAMS respondents (64.4% aged <30 years; 18.9% Hispanic, 26.2% non-Hispanic Black, 36.3% non-Hispanic White, and 18.6% other race or ethnicity) with a Medicaid-paid birth. Based on adjusted estimates, a 100% FPL increase in postpartum Medicaid eligibility was associated with a 5.1 percentage point (pp) increase in reported postpartum Medicaid enrollment, no change in commercial coverage, and a 6.6 pp decline in uninsurance. This represents a 40% reduction in postpartum uninsurance after a Medicaid-paid birth compared with the prepolicy baseline of 16.7%. In subgroup analyses by race and ethnicity, uninsurance reductions were observed only among White and Black non-Hispanic individuals; Hispanic individuals had no change. No policy-associated changes were observed in other outcomes. Conclusions and Relevance: In this cohort study, continuous Medicaid eligibility during the COVID-19 PHE was associated with significantly reduced postpartum uninsurance for people with Medicaid-paid births, but was not associated with postpartum visit attendance, contraception use, breastfeeding, or depressive symptoms at approximately 4 months postpartum. These findings, though limited to the context of the COVID-19 PHE, may offer preliminary insight regarding the potential impact of post-pandemic postpartum Medicaid eligibility extensions. Collection of longer-term and more comprehensive follow-up data on postpartum health care and health will be critical to evaluating the effect of ongoing postpartum policy interventions.

Disparities in Mistreatment During Childbirth.

Importance: Lack of respectful maternity care may be a key factor associated with disparities in maternal health. However, mistreatment during childbirth has not been widely documented in the US. Objectives: To estimate the prevalence of mistreatment by health care professionals during childbirth among a representative multistate sample and to identify patient characteristics associated with mistreatment experiences. Design, Setting, and Participants: This cross-sectional study used representative survey data collected from respondents to the 2020 Pregnancy Risk and Monitoring System in 6 states and New York City who had a live birth in 2020 and participated in the Postpartum Assessment of Health Survey at 12 to 14 months' post partum. Data were collected from January 1, 2021, to March 31, 2022. Exposures: Demographic, social, clinical, and birth characteristics that have been associated with patients' health care experiences. Main Outcomes and Measures: Any mistreatment during childbirth, as measured by the Mistreatment by Care Providers in Childbirth scale, a validated measure of self-reported experiences of 8 types of mistreatment. Survey-weighted rates of any mistreatment and each mistreatment indicator were estimated, and survey-weighted logistic regression models estimated odds ratios (ORs) and 95% CIs. Results: The sample included 4458 postpartum individuals representative of 552 045 people who had live births in 2020 in 7 jurisdictions. The mean (SD) age was 29.9 (5.7) years, 2556 (54.4%) identified as White, and 2836 (58.8%) were commercially insured. More than 1 in 8 individuals (13.4% [95% CI, 11.8%-15.1%]) reported experiencing mistreatment during childbirth. The most common type of mistreatment was being "ignored, refused request for help, or failed to respond in a timely manner" (7.6%; 95% CI, 6.5%-8.9%). Factors associated with experiencing mistreatment included being lesbian, gay, bisexual, transgender, queer identifying (unadjusted OR [UOR], 2.3; 95% CI, 1.4-3.8), Medicaid insured (UOR, 1.4; 95% CI, 1.1-1.8), unmarried (UOR, 0.8; 95% CI, 0.6-1.0), or obese before pregnancy (UOR, 1.3; 95% CI, 1.0-1.7); having an unplanned cesarean birth (UOR, 1.6; 95% CI, 1.2-2.2), a history of substance use disorder (UOR, 2.6; 95% CI, 1.3-5.1), experienced intimate partner or family violence (UOR, 2.3; 95% CI, 1.3-4.2), mood disorder (UOR, 1.5; 95% CI, 1.1-2.2), or giving birth during the COVID-19 public health emergency (UOR, 1.5; 95% CI, 1.1-2.0). Associations of mistreatment with race and ethnicity, age, educational level, rural or urban geography, immigration status, and household income were ambiguous. Conclusions and Relevance: This cross-sectional study of individuals who had a live birth in 2020 in 6 states and New York City found that mistreatment during childbirth was common. There is a need for patient-centered, multifaceted interventions to address structural health system factors associated with negative childbirth experiences.

Racial And Ethnic Inequities In Postpartum Depressive Symptoms, Diagnosis, And Care In 7 US Jurisdictions.

Understanding whether racial and ethnic inequities exist along the postpartum mental health care continuum is vital because inequitable identification of depression can lead to inequitable referral to and receipt of care. We aimed to expand on existing cross-sectional and single-state data documenting potential racial and ethnic disparities in postpartum depression care. Using early (from two to six months) and late (from twelve to fourteen months) postpartum survey data from seven US jurisdictions, we documented patterns of early postpartum depressive symptoms, perinatal mood and anxiety disorder (PMAD) diagnosis, and receipt of postpartum mental health care overall and by racial and ethnic identity. Of 4,542 people who delivered live births in 2020, 11.8 percent reported early postpartum depressive symptoms. Among the sample with these symptoms, only 25.4 percent reported receiving a PMAD diagnosis, and 52.8 percent reported receiving some form of postpartum mental health care. There were no significant differences in diagnosis by race and ethnicity. Respondents identifying as Asian; Native Hawaiian or Pacific Islander; Southwest Asian, Middle Eastern, or North African; Hispanic; and non-Hispanic Black were significantly less likely than non-Hispanic White respondents to receive mental health care, demonstrating stark inequities in the management of postpartum depressive symptoms. Policies mandating and reimbursing universal postpartum depression screening, facilitating connection to care, reducing insurance coverage gaps, and enhancing clinician training in culturally responsive care may promote equitable postpartum mental health care.

Racial and ethnic disparities in the use of antipsychotic medication: a systematic review and meta-analysis.

OBJECTIVE: To conduct a systematic review and meta-analysis of published evidence on ethnic or racial disparities in the outpatient use versus non-use of antipsychotics and in the outpatient use of newer versus older antipsychotics. METHOD: Electronic databases were searched for potentially relevant studies. Two independent reviewers conducted the review in three stages: title review, abstract review and full-text review. Included studies were those that: (a) report measures of disparity in the outpatient use of antipsychotic drugs in clearly defined racial or ethnic groups (b) have a primary focus on ethnic or racial disparities, and (c) have adjusted for factors known to influence medicine use. Odds ratios were pooled following the inverse-variance method of weighting effect sizes. I (2) statistics were calculated to quantify the amount of variation that is likely due to heterogeneity between studies. Funnel plots were produced and Egger's statistic was calculated to assess potential publication bias. RESULTS: No significant differences were found in the odds of using any antipsychotics among African Americans (OR = 1.01, CI = 0.99-1.02) compared with non-African Americans and among Latinos (OR = 0.98, CI = 0.86-1.13) compared with non-Latinos. Small to moderate but statistically non-significant disparities were also noted in other ethnic groups: Asians (OR = 1.10, CI = 0.88-1.36), Maoris (OR = 0.78, CI = 0.53-1.13) and Pacific Islanders (OR = 0.97, CI = 0.84-1.11). Among those who received antipsychotic medication, African Americans (OR = 0.62, CI = 0.50-0.78) and Latinos (OR = 0.77, CI = 0.73-0.81) appeared to have lower odds of receiving newer antipsychotics compared with non-African Americans and non-Latinos. CONCLUSION: No significant ethnic disparities in the use versus non-use of any antipsychotics were observed, but, among those who received antipsychotic treatment, ethnic minorities were consistently less likely than non-ethnic minorities to be treated with newer antipsychotics.

Inter-jurisdictional cooperation on pharmaceutical product listing agreements: views from Canadian provinces.

BACKGROUND: Confidential product listing agreements (PLAs) negotiated between pharmaceutical manufacturers and individual health care payers may contribute to unwanted price disparities, high administrative costs, and unequal bargaining power within and across jurisdictions. In the context of Canada's decentralized health system, we aimed to document provincial policy makers' perceptions about collaborative PLA negotiations. METHODS: We conducted semi-structured telephone interviews with a senior policy maker from nine of the ten Canadian provinces. We conducted a thematic analysis of interview transcripts to identify benefits, drawbacks, and barriers to routine collaboration on PLA negotiations. RESULTS: Canadian policy makers expressed support for joint negotiations of PLAs in principle, citing benefits of increased bargaining power and reduced inter-jurisdictional inequities in drug prices and formulary listings. However, established policy institutions and the politics of individual jurisdictional authority are formidable barriers to routine PLA collaboration. Achieving commitment to a joint process may be difficult to sustain among heterogeneous and autonomous partners. CONCLUSIONS: Though collaboration on PLA negotiation is an extension of collaboration on health technology assessment, it is a very significant next step that requires harmonization of the outcomes of decision-making processes. Views of policy makers in Canada suggest that sustaining routine collaborations on PLA negotiations may be difficult unless participating jurisdictions have similar policy institutions, capacities to implement coverage decisions, and local political priorities.

Perinatal Care Changes During COVID-19: A Population-Based Analysis by Race/Ethnicity.

INTRODUCTION: The COVID-19 public health emergency created unprecedented disruptions in the use of healthcare services, which could have affected long-standing racial‒ethnic disparities in maternal care use and outcomes. This study evaluates population-level changes in perinatal health services associated with the COVID-19 pandemic overall and by maternal race‒ethnicity. METHODS: In this analysis of all U.S. live births from 2016 to 2020, interrupted time-series analysis was used to estimate the change in the mean number of prenatal care visits and rates of hospital birth, labor induction, and cesarean delivery associated with the start of the pandemic (March 2020) overall and by maternal race‒ethnicity. Analyses were conducted in 2022. RESULTS: The start of the pandemic was associated with overall decreases in the mean number of prenatal care visits, decreases in hospital birth rates, and increases in labor induction rates. The mean number of prenatal care visits decreased similarly for all racial‒ethnic groups, whereas reductions in hospital births were largest for non-Hispanic White individuals, and increases in labor induction were largest for non-Hispanic White and non-Hispanic Asian or Pacific Islander individuals. CONCLUSIONS: Among all U.S. live births, the COVID-19 pandemic was associated with modest overall changes in perinatal care, with differential changes by maternal race‒ethnicity. Differential changes in perinatal services may have implications for racial-ethnic maternal health disparities.

Differences in Self-Reported and Billed Postpartum Visits Among Medicaid-Insured Individuals.

Importance: State Medicaid programs have recently implemented several policies to improve access to health care during the postpartum period. Understanding whether these policies are succeeding will require accurate measurement of postpartum visit use over time and across states; however, current estimates of use vary substantially between data sources. Objectives: To examine disagreement between postpartum visit use reported in the Pregnancy Risk Assessment Monitoring System (PRAMS) and Medicaid claims and assess whether insurance transitions from Medicaid at the time of childbirth to other insurance types after delivery are associated with the degree of disagreement. Design, Setting, and Participants: This cross-sectional study was conducted among individuals in South Carolina after delivery who had completed a PRAMS survey and for whom Medicaid was the payer of their delivery care. PRAMS responses from 2017 to 2020 were linked to inpatient, outpatient, and physician Medicaid claims; survey-weighted logistic regression models were then used to examine the association between postpartum insurance transitions and data source disagreement. Data were analyzed from February through October 2023. Exposure: Insurance transition type: continuous Medicaid, Medicaid to private insurance, Medicaid to no insurance, and Emergency Medicaid to no insurance. Main Outcome and Measure: Data source disagreement due to reporting a postpartum visit in PRAMS without a Medicaid claim for a visit or having a Medicaid claim for a visit without reporting a postpartum visit in PRAMS. Results: Among 836 PRAMS respondents enrolled in Medicaid at delivery (663 aged 20-34 years [82.9%]), a mean of 85.7% (95% CI, 82.1%-88.7%) reported a postpartum visit in PRAMS and a mean of 61.6% (95% CI, 56.9%-66.0%) had a Medicaid claim for a postpartum visit. Overall, 253 respondents (30.3%; 95% CI, 26.1%-34.7%) had data source disagreement: 230 individuals (27.2%; 95% CI, 23.2%-31.5%) had a visit in PRAMS without a Medicaid claim, and 23 individuals (3.1%; 95% CI, 1.8%-5.2%) had a Medicaid claim without a visit in PRAMS. Compared with individuals continuously enrolled in Medicaid, those who transitioned to private insurance after delivery and those who were uninsured after delivery and had Emergency Medicaid at delivery had an increase in the probability of data source agreement of 15.8 percentage points (95% CI, 2.6-29.1 percentage points) and 37.2 percentage points (95% CI, 19.6-54.8 percentage points), respectively. Conclusions and Relevance: This study's findings suggest that Medicaid claims may undercount postpartum visits among people who lose Medicaid or switch to private insurance after childbirth. Accounting for these insurance transitions may be associated with better claims-based estimates of postpartum care.

Late Postpartum Coverage Loss Before COVID-19: Implications For Medicaid Unwinding.

Using unique Pregnancy Risk Assessment Monitoring System follow-up data from before the COVID-19 pandemic, we found that only 68 percent of prenatal Medicaid enrollees maintained continuous Medicaid coverage through nine or ten months postpartum. Of the prenatal Medicaid enrollees who lost coverage in the early postpartum period, two-thirds remained uninsured nine to ten months postpartum. State postpartum Medicaid extensions could prevent a return to prepandemic rates of postpartum coverage loss.

The Health And Social Needs Of Medicaid Beneficiaries In The Postpartum Year: Evidence From A Multistate Survey.

As of September 2023, thirty-seven states and Washington, D.C., had adopted the option in the American Rescue Plan Act of 2021 to extend pregnancy Medicaid eligibility to one year postpartum. To inform state initiatives to support this newly covered population, we conducted a representative survey of postpartum people in six states and New York City from January 2021 to March 2022. Compared with respondents who had commercial insurance at the time of childbirth, Medicaid respondents were less likely to have a usual source of care and reported less use of primary, specialty, and dental care in the postpartum year. Depression symptoms and social concerns such as food insecurity, intimate partner violence, and financial strain were significantly higher in the Medicaid population. Rates of anxiety symptoms, delaying or not getting needed care, and unsatisfactory child care were similar in both populations. Our findings suggest that postpartum Medicaid extensions should be coupled with state initiatives to address beneficiaries' health and social needs. National investments in data collection on postpartum people will be critical to support evidence-based policy making to improve maternal health and well-being.

Medicaid expansion and risk of eclampsia.

BACKGROUND: Eclampsia is an indicator of severe maternal morbidity and can be prevented through increased prenatal care access and early prenatal care utilization. The 2014 Medicaid expansion under the Patient Protection and Affordable Care Act allowed states to expand Medicaid coverage to nonelderly adults with incomes up to 138% of the federal poverty level. Its implementation has led to a significant increase in prenatal care access and utilization. OBJECTIVE: This study aimed to assess the association of Medicaid expansion under the Affordable Care Act with eclampsia incidence. STUDY DESIGN: This natural experiment study was based on US birth certificate data from January 2010 to December 2018 in 16 states that expanded Medicaid in January 2014 and in 13 states that did not expand Medicaid during the study period. The outcome was eclampsia incidence, the intervention was the implementation of the Medicaid expansion, and the exposure was state expansion status. Using the interrupted time series method, we compared temporal trends in the incidence of eclampsia before and after the intervention in expansion vs non-expansion states with adjustments for patient and hospital county characteristics. RESULTS: Of the 21,570,021 birth certificates analyzed, 11,433,862 (53.0%) were in expansion states and 12,035,159 (55.8%) were in the postintervention period. The diagnosis of eclampsia was recorded in 42,677 birth certificates or 19.8 per 10,000 (95% confidence interval, 19.6-20.0). The incidence of eclampsia was higher for Black people (29.1 per 10,000) than for White (20.7 per 10,000), Hispanic (15.3 per 10,000), and birthing people of other race and ethnicity (15.4 per 10,000). In the expansion states, the incidence of eclampsia increased during the preintervention period and decreased during the postintervention period; in the nonexpansion states, a reverse pattern was observed. A statistically significant difference was observed between expansion and nonexpansion states in temporal trends between the pre- and postintervention periods, with an overall 1.6% decrease (95% confidence interval, 1.3-1.9) in the incidence of eclampsia in expansion states compared with nonexpansion states. The results were consistent in subgroup analyses according to maternal race and ethnicity, education level (less than high school or high school and higher), parity (nulliparous or parous), delivery mode (vaginal or cesarean delivery), and poverty in the residence county (high or low). CONCLUSION: Implementation of the Affordable Care Act Medicaid expansion was associated with a small statistically significant reduction in the incidence of eclampsia. Its clinical significance and cost-effectiveness remain to be determined.