Oregon's Expansion of Prenatal Care Improved Utilization Among Immigrant Women.

Objectives To determine whether expanding Emergency Medicaid to cover prenatal care in Oregon affected maternal health outcomes for unauthorized immigrants. Methods This study takes place in Oregon from 2003 to 2015 and includes all Emergency Medicaid and Medicaid claims for women aged 12-51 with a pregnancy related claim. To isolate the effect of expanding access to prenatal care, we utilized a difference-in-differences approach that exploits the staggered rollout of the prenatal care program. The primary outcome was a composite measure of severe maternal morbidity and mortality. Additional outcomes include adequacy of prenatal care, detection of pregnancy complications and birth outcomes. Results A total of 213,746 pregnancies were included, with 35,182 covered by Emergency Medicaid, 12,510 covered by Emergency Medicaid Plus (with prenatal care), and 166,054 covered by standard Medicaid. Emergency Medicaid Plus coverage did not affect severe maternal morbidity (all pregnancies 0.05%, CI - 0.29; 0.39; high-risk pregnancies 2.20%, CI - 0.47; 4.88). The program did reduce inadequate care among all pregnancies (- 31.75%, 95% CI - 34.47; - 29.02) and among high risk pregnancies (- 38.60%, CI - 44.17; - 33.02) and increased diagnosis of gestational diabetes (6.24%, CI 4.36; 8.13; high risk pregnancies 10.48%, CI 5.87; 15.08), and poor fetal growth (7.37%, CI 5.69; 9.05; high risk pregnancies 5.34%, CI 1.00; 9.68). The program also increased diagnosis of pre-existing diabetes mellitus (all pregnancies 2.93%, CI 2.16; 3.69), hypertensive diseases of pregnancy (all pregnancies 1.28%, CI 0.52; 2.04) and a history of preterm birth (all pregnancies 0.87%, CI 0.27; 1.47). Conclusions for Practice Oregon's prenatal care expansion program produced positive effects for unauthorized immigrant women and their children.

Expanding comprehensive pregnancy care for Emergency Medicaid recipients: a cost-effectiveness analysis.

BACKGROUND: Emergency Medicaid is a restricted benefits program for individuals who have low-income status and who are immigrants. OBJECTIVE: This study aimed to compare the cost-effectiveness of 2 strategies of pregnancy coverage for Emergency Medicaid recipients: the federal minimum of covering the delivery only vs extended coverage to 60 days after delivery. STUDY DESIGN: A decision analytical Markov model was developed to evaluate the outcomes and costs of these policies, and the results in a theoretical cohort of 100,000 postpartum Emergency Medicaid recipients were considered. The payor perspective was adopted. Health outcomes and cost-effectiveness over a 1- and 3-year time horizon were investigated. All probabilities, utilities, and costs were obtained from the literature. Our primary outcome was the incremental cost-effectiveness ratio of the competing strategies. RESULTS: Extending Emergency Medicaid to 60 days after delivery was determined to be a cost-saving strategy. Providing postpartum and contraceptive care resulted in 33,900 additional people receiving effective contraception in the first year and prevented 7290 additional unintended pregnancies. Over 1 year, it resulted in a gain of 1566 quality-adjusted life year at a cost of $10,903 per quality-adjusted life year. By 3 years of policy change, greater improvements were observed in all outcomes, and the expansion of Emergency Medicaid became cost saving and the dominant strategy. CONCLUSION: The inclusion of postpartum care and contraception for immigrant women who have low-income status resulted in lower costs and improved health outcomes.

Disparities in postpartum contraceptive use among immigrant women with restricted Medicaid benefits.

BACKGROUND: The Emergency Medicaid program offers restricted Medicaid benefits for people who meet the same financial eligibility criteria as Traditional Medicaid recipients but do not meet the citizenship requirements for enrollment in Traditional Medicaid. By federal law, Emergency Medicaid covers care for life-threatening emergencies or a hospital admission for childbirth. No prenatal or postpartum care is covered. Most of the women enrolled in Emergency Medicaid are Latina. OBJECTIVE: We assessed postpartum visits and receipt of postpartum contraception and compared the outcomes for Emergency (restricted benefit) Medicaid recipients with those of Traditional (full-benefit) Medicaid recipients in Oregon and South Carolina, 2 states with similar-sized immigrant populations. STUDY DESIGN: We conducted a retrospective cohort study using linked Medicaid claims and birth certificate data of live births covered by Medicaid (Traditional and Emergency) between January 1, 2010 and September 30, 2017, in Oregon and South Carolina. Our analysis was at the individual level. Primary outcomes were postpartum visit attendance and receipt of postpartum contraception within 2 months. We examined differences in demographic and delivery characteristics by Medicaid type. If women received postpartum contraception, we compared the timing of receipt (immediate postpartum, ≤1 month, 1-2 months, and 2-6 months after delivery) by the type of Medicaid. Among women using contraception, we described the type of contraceptive received at each time point, stratified by Medicaid type. Associations between Medicaid type (Traditional vs Emergency) and postpartum visit attendance and contraception use were assessed using adjusted absolute predicted probabilities from logistic regression models. We ran models for the entire cohort and conducted a subanalysis restricted to only Latina women. RESULTS: Our study included 375,544 live births to 288,234 women, with 12.7% of births among Emergency Medicaid recipients. Women enrolled in Emergency Medicaid tended to be older (age >35 years; 18.1% vs 7.2%; P<.001) and were more likely to be multiparous (76.8% vs 60.8%; P<.001) and Latina (80.3% vs 9.5%; P<.001) than their Traditional Medicaid peers. Among women enrolled in Emergency Medicaid, the probability of having a postpartum visit was 6.1% (95% confidence interval, 5.9-6.4) compared with 58.8% (95% confidence interval, 58.6-58.9) for women covered by Traditional Medicaid. After 6 months following delivery, 97.6% of Emergency Medicaid recipients had no evidence of contraceptive use compared with 55.6% of Traditional Medicaid enrollees (P<.001). In our adjusted model, Emergency Medicaid recipients were also significantly less likely to receive postpartum contraception than Traditional Medicaid enrollees (1.9% vs 35.5%; 95% confidence interval, [1.8-2.1] vs [35.4-35.7]). We examined the role that race may play in postpartum contraceptive use by conducting a subanalysis restricted to Latina women only.Latinas with births covered by Emergency Medicaid had a 1.9% (95% confidence interval, 1.8-2.0) adjusted probability of postpartum contraception use within 2 months compared with 39.8% (95% confidence interval, 38.7-39.9) among Latinas enrolled in Traditional Medicaid. CONCLUSION: Women enrolled in Emergency Medicaid experience large disparities in postpartum care and contraceptive use. Policies that restrict Medicaid coverage following delivery exacerbate inequities in postpartum care, potentially leading to worse health outcomes for low-income immigrants and their children.