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.

Validity of Birth Certificate Data Compared With Hospital Discharge Data in Reporting Maternal Morbidity and Disparities.

A growing number of studies are using birth certificate data, despite data-quality concerns, to study maternal morbidity and associated disparities. We examined whether conclusions about the incidence of maternal morbidity, including Black-White disparities, differ between birth certificate data and hospitalization data. Using linked birth certificate and hospitalization data from California and Michigan for 2018 (N=543,469), we found that maternal morbidity measures using birth certificate data alone are substantially underreported and have poor validity. Furthermore, the degree of underreporting in birth certificate data differs between Black and White individuals and results in erroneous inferences about disparities. Overall, Black-White disparities were more modest in the birth certificate data compared with the hospitalization data. Birth certificate data alone are inadequate for studies of maternal morbidity and associated racial disparities.

State Variation in Severe Maternal Morbidity Among Individuals With Medicaid Insurance.

OBJECTIVE: To measure variation in delivery-related severe maternal morbidity (SMM) among individuals with Medicaid insurance by state and by race and ethnicity across and within states. METHODS: We conducted a pooled, cross-sectional analysis of the 2016-2018 TAF (Transformed Medicaid Statistical Information System Analytic Files). We measured overall and state-level rates of SMM without blood transfusion for all individuals with Medicaid insurance with live births in 49 states and Washington, DC. We also examined SMM rates among non-Hispanic Black and non-Hispanic White individuals with Medicaid insurance in a subgroup of 27 states (and Washington, DC). We generated unadjusted rates of composite SMM and the individual indicators of SMM that comprised the composite. Rate differences and rate ratios were calculated to compare SMM rates for non-Hispanic Black and non-Hispanic White individuals with Medicaid insurance. RESULTS: The overall rate of SMM without blood transfusion was 146.2 (95% CI 145.1-147.3) per 10,000 deliveries (N=4,807,143). Rates of SMM ranged nearly threefold, from 80.3 (95% CI 71.4-89.2) per 10,000 deliveries in Utah to 210.4 (95% CI 184.6-236.1) per 10,000 deliveries in Washington, DC. Non-Hispanic Black individuals with Medicaid insurance (n=629,774) experienced a higher overall rate of SMM (212.3, 95% CI 208.7-215.9) compared with non-Hispanic White individuals with Medicaid insurance (n=1,051,459); (125.3, 95% CI 123.2-127.4) per 10,000 deliveries (rate difference 87.0 [95% CI 82.8-91.2]/10,000 deliveries; rate ratio 1.7 [95% CI 1.7-1.7]). The leading individual indicator of SMM among all individuals with Medicaid insurance was eclampsia, although the leading indicators varied across states and by race and ethnicity. Many states were concordant in leading indicators among the overall, non-Hispanic Black, and non-Hispanic White populations (ie, in Oklahoma sepsis was the leading indicator for all three). Most states, however, were discordant in leading indicators across the three groups (ie, in Texas eclampsia was the leading indicator overall, pulmonary edema or acute heart failure was the leading indicator among the non-Hispanic Black population, and sepsis was the leading indicator among the non-Hispanic White population). CONCLUSION: Interventions aimed at reducing SMM and, ultimately, mortality among individuals with Medicaid insurance may benefit from the data generated from this study, which highlights states that have the greatest burden of SMM, the differences in rates among non-Hispanic Black populations compared with non-Hispanic White populations, and the leading indicators of SMM overall, by state, and by race and ethnicity.

Racial/ethnic disparities in costs, length of stay, and severity of severe maternal morbidity.

BACKGROUND: In contrast to other high-resource countries, the United States has experienced increases in the rates of severe maternal morbidity. In addition, the United States has pronounced racial and ethnic disparities in severe maternal morbidity, especially for non-Hispanic Black people, who have twice the rate as non-Hispanic White people. OBJECTIVE: This study aimed to examine whether the racial and ethnic disparities in severe maternal morbidity extended beyond the rates of these complications to include disparities in maternal costs and lengths of stay, which could indicate differences in the case severity. STUDY DESIGN: This study used California's linkage of birth certificates to inpatient maternal and infant discharge data for 2009 to 2011. Of the 1.5 million linked records, 250,000 were excluded because of incomplete data, for a final sample of 1,262,862. Cost-to-charge ratios were used to estimate costs from charges (including readmissions) after adjusting for inflation to December 2017. Mean diagnosis-related group-specific reimbursement was used to estimate physician payments. We used the Centers for Disease Control and Prevention definition of severe maternal morbidity, including readmissions up to 42 days after delivery. Adjusted Poisson regression models estimated the differential risk of severe maternal morbidity for each racial or ethnic group, compared with the non-Hispanic White group. Generalized linear models estimated the associations of race and ethnicity with costs and length of stay. RESULTS: Asian or Pacific Islander, Non-Hispanic Black, Hispanic, and other race or ethnicity patients all had higher rates of severe maternal morbidity than non-Hispanic White patients. The largest disparity was between non-Hispanic White and non-Hispanic Black patients, with unadjusted overall rates of severe maternal morbidity of 1.34% and 2.62%, respectively (adjusted risk ratio, 1.61; P<.001). Among patients with severe maternal morbidity, the adjusted regression estimates showed that non-Hispanic Black patients had 23% (P<.001) higher costs (marginal effect of $5023) and 24% (P<.001) longer hospital stays (marginal effect of 1.4 days) than non-Hispanic White patients. These effects changed when cases, such as cases where a blood transfusion was the only indication of severe maternal morbidity, were excluded, with 29% higher costs (P<.001) and 15% longer length of stay (P<.001). For other racial and ethnic groups, the increases in costs and length of stay were smaller than those observed for non-Hispanic Black patients, and many were not significantly different from non-Hispanic White patients. Hispanic patients had higher rates of severe maternal morbidity than non-Hispanic White patients; however, Hispanic patients had significantly lower costs and length of stay than non-Hispanic White patients. CONCLUSION: There were racial and ethnic differences in the costs and length of stay among patients with severe maternal morbidity across the groupings that we examined. The differences were especially large for non-Hispanic Black patients compared with non-Hispanic White patients. Non-Hispanic Black patients experienced twice the rate of severe maternal morbidity; in addition, the higher relative costs and longer lengths of stay for non-Hispanic Black patients with severe maternal morbidity support greater case severity in that population. These findings suggest that efforts to address racial and ethnic inequities in maternal health need to consider differences in case severity in addition to the differences in the rates of severe maternal morbidity and that these differences in case severity merit additional investigation.

Rural and Urban Differences in Insurance Coverage at Prepregnancy, Birth, and Postpartum.

OBJECTIVE: To measure insurance coverage at prepregnancy, birth, and postpartum, and insurance coverage continuity across these periods among rural and urban U.S. residents. METHODS: We performed a pooled, cross-sectional analysis of survey data from 154,992 postpartum individuals in 43 states and two jurisdictions that participated in the 2016-2019 PRAMS (Pregnancy Risk Assessment Monitoring System). We calculated unadjusted estimates of insurance coverage (Medicaid, commercial, or uninsured) during three periods (prepregnancy, birth, and postpartum), as well as insurance continuity across these periods among rural and urban U.S. residents. We conducted subgroup analyses to compare uninsurance rates among rural and urban residents by sociodemographic and clinical characteristics. We used logistic regression models to generate adjusted odds ratios (aORs) for each comparison. RESULTS: Rural residents experienced greater odds of uninsurance in each period and continuous uninsurance across all three periods, compared with their urban counterparts. Uninsurance was higher among rural residents compared with urban residents during prepregnancy (15.4% vs 12.1%; aOR 1.19, 95% CI 1.11-1.28], at birth (4.6% vs 2.8%; aOR 1.60, 95% CI 1.41-1.82), and postpartum (12.7% vs 9.8%, aOR 1.27, 95% CI 1.17-1.38]. In each period, rural residents who were non-Hispanic White, married, and with intended pregnancies experienced greater adjusted odds of uninsurance compared with their urban counterparts. Rural-urban differences in uninsurance persisted across both Medicaid expansion and non-expansion states, and among those with varying levels of education and income. Rural inequities in perinatal coverage were experienced by Hispanic, English-speaking, and Indigenous individuals during prepregnancy and at birth. CONCLUSION: Perinatal uninsurance disproportionately affects rural residents, compared with urban residents, in the 43 states examined. Differential insurance coverage may have important implications for addressing rural-urban inequities in maternity care access and maternal health.

Association of Health Insurance, Geography, and Race and Ethnicity With Disparities in Receipt of Recommended Postpartum Care in the US.

Importance: Little is known about the quality of postpartum care or disparities in the content of postpartum care associated with health insurance, rural or urban residency, and race and ethnicity. Objectives: To examine receipt of recommended postpartum care content and to describe variations across health insurance type, rural or urban residence, and race and ethnicity. Design, Settings, and Participants: This cross-sectional survey of patients with births from 2016 to 2019 used data from the Pregnancy Risk Assessment Monitoring System (43 states and 2 jurisdictions). A population-based sample of patients conducted by state and local health departments in partnership with the Centers for Disease Control and Prevention were surveyed about maternal experiences 2 to 6 months after childbirth (mean weighted response rate, 59.9%). Patients who attended a postpartum visit were assessed for content at that visit. Analyses were performed November 2021 to July 2022. Exposures: Medicaid or private health insurance, rural or urban residence, and race and ethnicity (non-Hispanic White or racially minoritized groups). Main Outcomes and Measures: Receipt of 2 postpartum care components recommended by national quality standards (depression screening and contraceptive counseling), and/or other recommended components (smoking screening, abuse screening, birth spacing counseling, eating and exercise discussions) with estimated risk-adjusted predicted probabilities and percentage-point (pp) differences. Results: Among the 138 073 patient-respondents, most (59.5%) were in the age group from 25 to 34 years old; 59 726 (weighted percentage, 40%) were insured by Medicaid; 27 721 (15%) were rural residents; 9718 (6%) were Asian, 24 735 (15%) were Black, 22 210 (15%) were Hispanic, 66 323 (60%) were White, and fewer than 1% were Indigenous (Native American/Alaska Native) individuals. Receipt of both depression screening and contraceptive counseling both significantly lower for Medicaid-insured patients (1.2 pp lower than private; 95% CI, -2.1 to -0.3), rural residents (1.3 pp lower than urban; 95% CI, -2.2 to -0.4), and people of racially minoritized groups (0.8 pp lower than White individuals; 95% CI, -1.6 to -0.1). The highest receipt of these components was among privately insured White urban residents (80%; 95% CI, 79% to 81%); the lowest was among privately insured racially minoritized rural residents (75%; 95% CI, 72% to 78%). Receipt of all other components was significantly higher for Medicaid-insured patients (6.1 pp; 95% CI, 5.2 to 7.0), rural residents (1.1 pp; 95% CI, 0.1 to 2.0), and people of racially minoritized groups (8.5 pp; 95% CI, 7.7 to 9.4). The highest receipt of these components was among Medicaid-insured racially minoritized urban residents (34%; 95% CI, 33% to 35%), the lowest was among privately insured White urban residents (19%; 95% CI, 18% to 19%). Conclusions and Relevance: The findings of this cross-sectional survey of postpartum individuals in the US suggest that inequities in postpartum care content were extensive and compounded for patients with multiple disadvantaged identities. Examining only 1 dimension of identity may understate the extent of disparities. Future studies should consider the content of postpartum care visits.

Racial/Ethnic Disparities in Postpartum Health Insurance Coverage Among Rural and Urban U.S. Residents.

Objective: Half of maternal deaths occur during the postpartum year, with data suggesting greater risks among Black, Indigenous, and people of color (BIPOC) and rural residents. Being insured after childbirth improves postpartum health-related outcomes, and recent policy efforts focus on extending postpartum Medicaid coverage from 60 days to 1 year postpartum. The purpose of this study is to describe postpartum health insurance coverage for rural and urban U.S. residents who are BIPOC compared to those who are white. Materials and Methods: Using data from the 2016-2019 Pregnancy Risk Assessment Monitoring System (n = 150,273), we describe health insurance coverage categorized as Medicaid, commercial, or uninsured at the time of childbirth and postpartum. We measured continuity of insurance coverage across these periods, focusing on postpartum Medicaid disruptions. Analyses were conducted among white and BIPOC residents from rural and urban U.S. counties. Results: Three-quarters (75.3%) of rural white people and 85.3% of urban white people were continuously insured from childbirth to postpartum, compared to 60.5% of rural BIPOC people and 65.6% of urban BIPOC people. Postpartum insurance disruptions were frequent among people with Medicaid coverage at childbirth, particularly among BIPOC individuals, compared to those with private insurance; 17.0% of rural BIPOC residents had Medicaid at birth and became uninsured postpartum compared with 3.4% of urban white people. Conclusions: Health insurance coverage at childbirth, postpartum, and across these timepoints varies by race/ethnicity and rural compared with urban residents. Policy efforts to extend postpartum Medicaid coverage may reduce inequities at the intersection of racial/ethnic identity and rural geography.

Rural Hospital Administrators' Beliefs About Safety, Financial Viability, and Community Need for Offering Obstetric Care.

Importance: Rural obstetric unit closures are associated with adverse maternal and infant health outcomes and are most common among low-birth volume facilities located in remote areas. Declining access to obstetric care is a concern in rural communities in the US. Objective: To assess rural hospital administrators' beliefs about safety, financial viability, and community need for offering obstetric care. Design Setting and Participants: Using the American Hospital Association Annual Survey to identify rural hospitals with obstetric units, we developed and conducted a national survey of a sample of rural hospitals that provided obstetric services in 2021. Obstetric unit managers or administrators at 292 rural hospitals providing obstetric services were surveyed from March to August 2021. Exposures: Local factors, clinical safety, workforce, and financial considerations for obstetric services at participating hospitals. Main Outcomes and Measures: Hospital-level decisions on maintaining obstetric care. Results: Of the 93 total responding hospitals (32% response rate), 33 (35.5%) were critical access hospitals, 60 (64.5%) were located in micropolitan rural counties; they had a median (IQR) average daily census of 22 (10-53) patients, and 48 (52.2%) had experienced a recent decline in births, with a median (IQR) of 274 (120-446) births in 2019. Respondents reported that the minimum number of annual births needed to safely provide obstetric care was 200 (IQR, 100-350). From a financial perspective, the minimum number of annual births needed was also 200 (IQR, 120-360). When making decisions about maintaining obstetric care, 51 (64.6%) responding hospitals listed their highest priority as meeting local community needs, 13 (16.5%) listed financial considerations, and 10 (12.7%) listed staffing. Overall, 23 (25%) responding hospitals were not sure they would continue providing obstetrics, or they expected to stop offering this service. Conclusions and Relevance: In this survey of US rural hospitals that offer obstetric services, many administrators indicated prioritizing local community needs for obstetric care over concerns about financial viability and staffing.

Severe Maternal Morbidity and Mortality Risk at the Intersection of Rurality, Race and Ethnicity, and Medicaid.

OBJECTIVE: We examined differences in rates of severe maternal morbidity and mortality (SMMM) among Medicaid-funded compared with privately insured hospital births through specific additive and intersectional risk by rural or urban geography, race and ethnicity, and clinical factors. METHODS: We used maternal discharge records from childbirth hospitalizations in the Healthcare Cost and Utilization Project's National Inpatient Sample from 2007 to 2015. We calculated predicted probabilities using weighted multivariable logistic regressions to estimate adjusted rates of SMMM, examining differences in rates by payer, rurality, race and ethnicity, and clinical factors. To assess the presence and extent of additive risk by payer, with other risk factors, on rates of SMMM, we estimated the proportion of the combined effect that was due to the interaction. RESULTS: In this analysis of 6,357,796 hospitalizations for childbirth, 2,932,234 were Medicaid funded and 3,425,562 were privately insured. Controlling for sociodemographic and clinical factors, the highest rate of SMMM (224.9 per 10,000 births) occurred among rural Indigenous Medicaid-funded births. Medicaid-funded births among Black rural and urban residents, and among Hispanic urban residents, also experienced elevated rates and significant additive interaction. Thirty-two percent (Bonferroni-adjusted 95% confidence interval, 19%-45%) of SMMM cases among patients with chronic heart disease were due to payer interaction, and 19% (Bonferroni-adjusted 95% confidence interval, 17%-22%) among those with cesarean birth were due to the interaction. CONCLUSIONS: Heightened rates of SMMM among Medicaid-funded births indicate an opportunity for tailored state and federal policy responses to address the particular maternal health challenges faced by Medicaid beneficiaries, including Black, Indigenous, and rural residents.

The effect of severe maternal morbidity on infant costs and lengths of stay.

OBJECTIVE: To examine the association between severe maternal morbidity (SMM) and infant health using the additional infant costs and length of stay (LOS) as markers of added clinical complexity. STUDY DESIGN: Secondary data analysis using California linked birth certificate-patient discharge data for 2009-2011 (N = 1,260,457). Regression models were used to estimate the association between SMM and infant costs and LOS. RESULTS: The 16,687 SMM-exposed infants experienced a $6550 (33%) increase in costs and a 0.7 (18%) day increase in LOS. Preterm infants had ($11,258 (18%) added costs and 1.3 days (8.1%) longer LOS) than term infants ($2539 (38%) added costs and 0.5 days (22%) longer LOS). CONCLUSIONS: SMM was associated with increased infant costs and LOS, suggesting that SMM may have adverse health effects for infants, including term infants. The relatively larger effect on costs indicates an increase in treatment intensity (clinical severity) greater than additional LOS.

A Comprehensive Analysis of the Costs of Severe Maternal Morbidity.

INTRODUCTION: The objectives of this study were to include readmissions and physician costs in the estimates of total costs of severe maternal morbidity (SMM), to consider the effect of SMM on maternal length of stay (LOS), and to examine these for the more restricted definition of SMM that excludes transfusion-only cases. METHODS: California linked birth certificate-patient discharge data for 2009 through 2011 (n = 1,262,862) with complete costs and LOS were used in a secondary data analysis. Cost-to-charge ratios were used to estimate costs from charges, adjusting for inflation. Physician payments were estimated from the mean payments for specific diagnosis-related groups. Generalized linear models estimated the association between SMM and costs and LOS. RESULTS: Excluding readmissions and physician costs, SMM was associated with a 60% increase in hospital costs (marginal effect [ME] $3,550) and a 33% increase in LOS (ME 0.9 days). These increased to 70% (ME $5,806) and 46% (ME 1.3 days) when physician costs and readmissions were included. The effects of SMM were roughly one-half as large for patients who only required a blood transfusion (49% [ME $4,056] and 31% [ME 0.9 days]) as for patients who had another indicator for SMM (93% [ME $7,664] and 62% [ME 1.7 days]). CONCLUSIONS: Postpartum hospital readmissions and physician costs are important and previously unreported contributors to the costs of SMM. Excess costs and LOS associated with SMM vary considerably by indication. Cost effects were larger than the LOS effects, indicating that SMM increases treatment intensity beyond increasing LOS, and decreasing SMM may have broader health and cost benefits than previously understood.

Perinatal insurance coverage and behavioural health-related maternal mortality.

Increases in postpartum maternal deaths, including a substantial number associated with behavioural health conditions, are a public health crisis and have contributed to overall increases in maternal mortality. A leading hypothesis to explain this pattern suggests lack of availability or continuity of resources for behavioural health treatment after delivery, often secondary to lapses in insurance coverage. Extending postpartum Medicaid coverage through the first year postpartum could mitigate excess morbidity and mortality among postpartum individuals, particularly those with behavioural health conditions.

Reproductive-Age Women's Experience of Accessing Treatment for Opioid Use Disorder: "We Don't Do That Here".

PURPOSE: For reproductive-age women, medications for opioid use disorder (OUD) decrease risk of overdose death and improve outcomes but are underutilized. Our objective was to provide a qualitative description of reproductive-age women's experiences of seeking an appointment for medications for OUD. METHODS: Trained female callers placed telephone calls to a representative sample of publicly listed opioid treatment clinics and buprenorphine providers in Florida, Kentucky, Massachusetts, Michigan, Missouri, North Carolina, Tennessee, Virginia, Washington, and West Virginia to obtain appointments to receive medication for OUD. Callers were randomly assigned to be pregnant or non-pregnant and have private or Medicaid-based insurance to assess differences in the experiences of access by these characteristics. The callers placed 28,651 uniquely randomized calls, 10,117 to buprenorphine-waivered prescribers and 754 to opioid treatment programs. Open-ended, qualitative data were obtained from the callers about the access experiences and were analyzed using a qualitative, iterative inductive-deductive approach. From all 28,651 total calls, there were 17,970 unique free-text comments to the question "Please give an objective play-by-play of the description of what happened in this conversation." FINDINGS: Analysis demonstrated a common path to obtaining an appointment. Callers frequently experienced long hold times, multiple transfers, and difficult interactions. Clinic receptionists were often mentioned as facilitating or obstructing access. Pregnant callers and those with Medicaid noted more barriers. Obtaining an appointment was commonly difficult even for these persistent, trained callers. CONCLUSIONS: Interventions are needed to improve the experiences of reproductive-age women as they enter care for OUD, especially for pregnant women and those with Medicaid coverage.

Health Care Use by Commercially Insured Postpartum and Nonpostpartum Women in the United States.

OBJECTIVE: To compare the type, frequency, and timing of health care use among commercially insured postpartum and nonpostpartum women. METHODS: This retrospective cohort study used data from a large national commercial claims database. Women between 18 and 44 years of age who gave birth in 2016 (n=149,563) and women who were neither pregnant nor postpartum between 2015 and 2017 (n=2,048,831) (nonpostpartum) were included. We examined hospitalization, and preventive visits, problem visits, and emergency department (ED) visits among postpartum women during the early postpartum period (less than 21 days after childbirth), the postpartum period (21-60 days postpartum), and extended postpartum period (61-365 days after childbirth). Visits among nonpostpartum women were assessed during time periods of equivalent duration. RESULTS: Almost 24% of postpartum women had a problem visit in the early postpartum period, compared with 19.7% of nonpostpartum women (adjusted difference 4.8 percentage points [95% CI 4.6-5.0]). Approximately 3% of postpartum women had an early ED visit, more than double the percentage among nonpostpartum women (adjusted difference 2.3 percentage points [95% CI 2.2-2.4]). Both problem visits and ED visits among postpartum women remained elevated relative to nonpostpartum women during the postpartum and extended postpartum periods. Although postpartum women were more likely than nonpostpartum women to receive preventive care during the early and postpartum periods, only 43% of postpartum women had a preventive visit during the extended postpartum period, a rate 1.8 (95% CI -2.1 to -1.5) percentage points lower than that of nonpostpartum women. Adjusted hospitalization rates among postpartum women in the early (0.8%), postpartum (0.3%), and extended postpartum (1.4%) periods were higher than those of nonpostpartum women (0.1%, 0.2%, and 1.6%, respectively). CONCLUSIONS: Commercially insured postpartum women use more health care than nonpostpartum women, including inpatient care. Differences are largest in the early postpartum period and persist beyond 60 days postpartum.

Racial and Ethnic Diversity in the Nursing Workforce: A Focus on Maternity Care.

Racial and ethnic inequities in health are a national crisis requiring engagement across a range of factors, including the health care workforce. Racial inequities in maternal and infant health are an increasing focus of attention in the wake of rising rates of maternal morbidity and mortality in the United States. Efforts to achieve racial equity in childbirth should include attention to the nurses who provide care before and during pregnancy, at childbirth, and postpartum.

Factors Associated With Postpartum Uninsurance Among Medicaid-Paid Births.

Importance: To reduce postpartum uninsurance and improve postpartum health, the American Rescue Plan included an option for states to extend pregnancy-related Medicaid from 60 days to 1 year after childbirth. Recent estimates of postpartum uninsurance among Medicaid-paid births would provide information on who would benefit from state adoption of this extension. Objective: To estimate rates of postpartum uninsurance among individuals with Medicaid-paid births. Design Setting and Participants: This cross-sectional study used survey data from the 2015 to 2018 Pregnancy Risk Assessment Monitoring System (PRAMS), a representative sample of births in 43 states and New York City, New York, and included PRAMS participants for whom Medicaid was the primary payer for childbirth. The mean weighted PRAMS response rate was 60.9% for the sites and years included in this study. The data were analyzed from December 2020 to January 2021. Interventions or Exposures: Self-reported postpartum uninsurance measured at the time of the PRAMS survey (mean [interquartile range], 4.2 (3.0-5.0) months after birth). Main Outcomes and Measures: Survey-weighted rates of postpartum uninsurance and 95% CIs overall, by state, by state Medicaid expansion status, and by maternal sociodemographic characteristics. Adjusted odds ratios of the association between maternal characteristics and postpartum uninsurance. Results: We identified 63 370 respondents with a Medicaid-paid birth. Of these, 22 016 (41.1%) were non-Hispanic White individuals, 17 442 (22.0%) non-Hispanic Black individuals, 6808 (13.3%) Spanish-speaking Hispanic individuals, 7000 (13.7%) English-speaking Hispanic individuals, 2410 (4.0%) Asian/Pacific Islander individuals, and 3894 (1.3%) Indigenous individuals. Of these, 41.7% were no longer insured by Medicaid postpartum and 22.0% were uninsured postpartum. The postpartum uninsurance rate was 3 times higher in Medicaid nonexpansion states (36.8%) compared with expansion states (12.8%). Postpartum uninsurance varied significantly across states, ranging from 1.7% in Massachusetts to 56.7% in Texas. There were substantial racial and ethnic disparities in postpartum uninsurance: 54.9% of Hispanic, Spanish-speaking individuals (adjusted odds ratio [aOR], 6.2; 95% CI, 5.5-7.0) and 42.8% of Indigenous respondents reported postpartum uninsurance (aOR, 4.3; 95% CI, 3.8-4.9) compared with 15.2% of non-Hispanic White respondents. The odds of postpartum uninsurance was higher among unmarried people (aOR, 1.3 compared with married people; 95% CI, 1.2-1.4), those 35 years and older (aOR, 1.5 compared with those younger than 20 years; 95% CI, 1.2-1.9) and those with lower levels of education (aOR, 0.8 for more than high school compared with less than high school; 95% CI, 0.7-0.9). Conclusions and Relevance: In this cross-sectional survey study of 43 states, a high proportion of people with Medicaid-paid births were uninsured in the postpartum period, particularly those living in Medicaid nonexpansion states. The study findings suggest that state extensions of pregnancy-related Medicaid eligibility through the first year postpartum could disproportionately benefit Hispanic and Indigenous people, unmarried people, those with lower education levels, and those living in Medicaid nonexpansion states.

Practice Patterns of Physicians and Nurse Practitioners in Primary Care.

BACKGROUND: Primary care practices increasingly include nurse practitioners (NPs), in addition to physicians. Little is known about how the patient mix and clinical activities of colocated physicians and NPs compare. OBJECTIVES: To describe the clinical activities of NPs, compared with physicians. RESEARCH DESIGN: We used claims and electronic health record data from athenahealth Inc., on primary care practices in 2017 and a cross-sectional analysis with practice fixed effects. SUBJECTS: Patients receiving treatment from physicians and NPs within primary care practices. MEASURES: First, we measured patient characteristics (payer, age, sex, race, chronic condition count) and visit characteristics (new patient, scheduled duration, same-day visit, after-hours visit). Second, we measured procedures performed and diagnoses recorded during each visit. Finally, we measured daily quantity (visit volume, minutes scheduled for patient care, total work relative value units billed) of care. RESULTS: Relative to physicians, NPs treated younger and healthier patients. NPs also had a larger share of patients who were female, non-White, and covered by Medicaid, commercial insurance, or no insurance. NPs scheduled longer appointments and treated more patients on a same-day or after-hours basis. On average, "overlapping" services-those performed by NPs and physicians within the same practice-represented 92% of all service volume. The small share of services performed exclusively by physicians reflected greater clinical intensity. On a daily basis, NPs provided fewer and less intense visits than physicians within the same practice. CONCLUSIONS: Our findings suggest considerable overlap between the clinical activities of colocated NPs and physicians, with some differentiation based on intensity of services provided.

Medicaid Expansion Improved Perinatal Insurance Continuity For Low-Income Women.

Insurance churn, or moving between different insurance plans or between insurance and uninsurance, is common during the perinatal period. We used survey data from the 2012-17 Pregnancy Risk Assessment Monitoring System to estimate the impact of Affordable Care Act-related state Medicaid expansions on continuity of insurance coverage for low-income women across three time points: preconception, delivery, and postpartum. We found that Medicaid expansion resulted in a 10.1-percentage-point decrease in churning between insurance and uninsurance, representing a 28 percent decrease from the prepolicy baseline in expansion states. This decrease was driven by a 5.8-percentage-point increase in the proportion of women who were continuously insured and a 4.2-percentage-point increase in churning between Medicaid and private insurance. Medicaid expansion improved insurance continuity in the perinatal period for low-income women, which may improve the quality of perinatal health care, but it also increased churning between public and private health insurance.