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).

Coverage Disruptions and Transitions Across the ACA's Medicaid/Marketplace Income Cutoff.

BACKGROUND: The Affordable Care Act takes a "patchwork" approach to expanding coverage: Medicaid covers individuals with incomes 138% of the federal poverty level (FPL) in expansion states, while subsidized Marketplace insurance is available to those above this income cutoff. OBJECTIVE: To characterize the magnitude of churning between Medicaid and Marketplace coverage and to examine the impact of the 138% FPL income cutoff on stability of coverage. DESIGN: We measured the incidence of transitions between Medicaid and Marketplace coverage. Then, we used a differences-in-differences framework to compare insurance churning in Medicaid expansion and non-expansion states, before and after the ACA, among adults with incomes 100-200% of poverty. PARTICIPANTS: Non-elderly adult respondents of the Medical Expenditure Panel Survey 2010-2018 MAIN MEASURES: The annual proportion of adults who (1) transitioned between Medicaid and Marketplace coverage; (2) experienced any coverage disruption. KEY RESULTS: One million U.S. adults transitioned between Medicaid and Marketplace coverage annually. The 138% FPL cutoff in expansion states was not associated with an increase in insurance churning among individuals with incomes close to the cutoff. CONCLUSIONS: Transitions between Medicaid and Marketplace insurance are uncommon-far lower than pre-ACA analyses predicted. The 138% income cutoff does not to contribute significantly to insurance disruptions.

County-level Predictors of Growth in Community-based Primary Care Use Among Veterans.

BACKGROUND: The 2014 Choice Act expanded the Veterans Health Administration's (VA) capacity to purchase services for VA enrollees from community providers, yet little is known regarding the growth of Veterans' primary care use in community settings. OBJECTIVES: The aim was to measure county-level growth in VA community-based primary care (CBPC) penetration following the Choice Act and to assess whether CBPC penetration increased in rural counties with limited access to VA facilities. DATA AND SAMPLE: A total of 3132 counties from VA administrative data from 2015 to 2018, Area Health Resources Files, and County Health Rankings. ANALYSIS: We defined the county-level CBPC penetration rate as the proportion of VA-purchased primary care out of all VA-purchased primary care (ie, within and outside VA). We estimated county-level multivariate linear regression models to assess whether rurality and supply of primary care providers and health care facilities were significantly associated with CBPC growth. RESULTS: Nationally, CBPC penetration rates increased from 2.7% in 2015 to 7.3% in 2018. The rurality of the county was associated with a 2-3 percentage point (pp) increase in CBPC penetration growth (P<0.001). The presence of a VA facility was associated with a 1.7 pp decrease in CBPC penetration growth (P<0.001), while lower primary care provider supply was associated with a 0.6 pp increase in CBPC growth (P<0.001). CONCLUSION: CBPC as a proportion of all VA-purchased primary care was small but increased nearly 3-fold between 2015 and 2018. Greater increases in CBPC penetration were concentrated in rural counties and counties without a VA facility, suggesting that community care may enhance primary care access in rural areas with less VA presence.

Federalism Complicates the Response to the COVID-19 Health and Economic Crisis: What Can Be Done?

Federalism has complicated the US response to the novel coronavirus. States' actions to address the pandemic have varied widely, and federal and state officials have provided conflicting messages. This fragmented approach has surely cost time and lives. Federalism will shape the long-term health and economic impacts of COVID-19, including plans for the future, for at least two reasons: First, federalism exacerbates inequities, as some states have a history of underinvesting in social programs, especially in certain communities. Second, many of the states with the deepest needs are poorly equipped to respond to emergencies due to low taxes and distrust of government, leading to inadequate infrastructure. These dynamics are not new, but they have been laid bare by this crisis. What can policy makers do to address the inequities in health and economic outcomes that federalism intensifies? The first section of this article offers a case study of the Mississippi Delta to illustrate the role of federalism in perpetuating the connection between place, health, and economics. The second section examines challenges that safety net programs will face when moving beyond the acute phase of COVID-19. The final section explores near-, middle-, and long-term policy options to mitigate federalism's harmful side effects.

Have the ACA's Exchanges Succeeded? It's Complicated.

The fight over health insurance exchanges epitomizes the rapid evolution of health reform politics in the decade since the passage of the Affordable Care Act (ACA). The ACA's drafters did not expect the exchanges to be contentious because they would expand private insurance coverage to low- and middle-income individuals who were increasingly unable to obtain employer-sponsored health insurance. Instead, exchanges became one of the primary fronts in the war over Obamacare. Have the exchanges been successful? The answer is not straightforward and requires a historical perspective through a federalism lens. What the ACA has accomplished has depended largely on whether states were invested in or resistant to implementation, as well as individual decisions by state leaders working with federal officials. Our account demonstrates that the states that have engaged with the ACA most consistently appear to have experienced greater exchange-related success. But each aspect of states' engagement with or resistance to the ACA must be counted to fully paint this picture, with significant variation among states. This variation should give pause to those considering next steps in health reform, because state variation can mean innovation and improvement but also lack of coverage, disparities, and diminished access to care.

Risk Factors for Early Disenrollment From Colorado's Affordable Care Act Marketplace.

BACKGROUND: Midyear disenrollment from Marketplace coverage may have detrimental effects on continuity of care and risk pool stability of individual health insurance markets. OBJECTIVE: The main objective of this study was to assess associations between insurance plan characteristics, individual and area-level demographics, and disenrollment from Marketplace coverage. DATA: All payer claims data from individual market enrollees, 2014-2016. STUDY DESIGN: We estimated Cox proportional hazards models to assess the relationship between plan actuarial value and Marketplace enrollment. The primary outcome was disenrollment from Marketplace coverage before the end of the year. We also calculated the proportion of enrollees who transitioned to other coverage after leaving the Marketplace, and identified demographic and area-level factors associated with early disenrollment. Finally, we compared monthly utilization rates between those who disenrolled early and those who maintained coverage. RESULTS: Nearly 1 in 4 Marketplace beneficiaries disenrolled midyear. The hazard rate of disenrollment was 30% lower for individuals in plans receiving cost-sharing reductions and 21% lower for those enrolled in gold plans, compared with silver plans without cost-sharing subsidies. Young adults had a 70% increased hazard of disenrollment compared with older adults. Those who disenrolled midyear had greater hospital and emergency department utilization before disenrollment compared with those who maintained continuous coverage. CONCLUSIONS: Plan generosity is significantly associated with lower disenrollment rates from Marketplace coverage. Reducing churning in Affordable Care Act Marketplaces may improve continuity of care and insurers' ability to accurately forecast the health care costs of their enrollees.

The Impact of Medicaid Expansion on Continuous Enrollment: a Two-State Analysis.

BACKGROUND: Discontinuous Medicaid insurance erodes access to care, increases administrative costs, and exposes enrollees to substantial out-of-pocket spending. OBJECTIVE: To assess the impact of Medicaid expansion under the Affordable Care Act on continuity of Medicaid coverage among those enrolled prior to expansion. DESIGN: Using a difference-in-differences framework, we compared Colorado, a state that expanded Medicaid, to Utah, a nonexpansion state, before and after Medicaid expansion implementation. PARTICIPANTS: Adults ages 18-62 who were enrolled in Medicaid coverage in Colorado and Utah prior to expansion, from the Utah and Colorado All Payer Claims Databases, 2013-2015. MAIN MEASURES: The primary outcomes were the duration of Medicaid enrollment and rates of disrupted coverage. KEY RESULTS: Following Medicaid expansion, enrollees in Colorado gained an additional 2 months of coverage over two years of follow-up and were 16 percentage points less likely to experience a coverage disruption in a given year relative to enrollees in Utah. CONCLUSIONS: Increasing Medicaid eligibility levels under the Affordable Care Act appears to be an effective strategy to reduce churning in the Medicaid program, with important implications for other states that are considering Medicaid expansion.

Safeguarding Research Using Federal Health Insurance Data.

This Viewpoint discusses the importance of researcher access to federal health care data following a CMS decision to limit the use of physical data and proposes solutions to maintain access and security.

Qualitative perspectives of primary care providers who treat Medicaid managed care patients.

BACKGROUND: Declining job satisfaction and concurrent reductions in Medicaid participation among primary care providers have been documented, but there is limited qualitative work detailing their first-hand experiences treating Medicaid patients. The objective of this study is to describe the experiences of some primary care providers who treat Medicaid patients using in-depth qualitative analysis. METHODS: We conducted qualitative interviews with 15 primary care providers treating Medicaid patients in a Northeastern state. Participant recruitment efforts focused on including different types of primary care providers practicing in diverse settings. Qualitative interviews were conducted using a semi-structured interview protocol. We developed a coding scheme to analyze interview transcripts and identify themes. RESULTS: Providers expressed challenges effectively meeting their patients' needs under current policy. They described low Medicaid reimbursement and underinvestment in care coordination programs to adequately address the social determinants of health. Providers shared other concerns including poor access to behavioral health services, discontinuous Medicaid coverage due to enrollment and renewal policies, and limited reimbursement for alternative pain treatment. Providers offered their own suggestions for the allocation of financial investments, Medicaid policy, and primary care practice. CONCLUSIONS: Underinvestment in primary care in Medicaid may detract from providers' professional satisfaction and hinder care coordination for Medicaid patients with complex healthcare needs. Policy solutions that improve the experience of primary care providers serving Medicaid patients are urgently needed to ensure sustainability of the workforce and improve care delivery.

Georgia Pathways-Partial Medicaid Expansion With Work Requirements and Premiums.

This Viewpoint discusses the Georgia Pathways to Coverage program, which is the first state program that partially expands Medicaid eligibility to low-income adults with work requirements.

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.

COVID-19 Medicaid Continuous Enrollment Provision Yielded Gains In Postpartum Continuity Of Coverage.

The Medicaid continuous enrollment provision mandated by the Families First Coronavirus Response Act of 2020 effectively prohibited the termination of enrollees from Medicaid during the COVID-19 public health emergency, including people enrolled in Medicaid during pregnancy. Using data from the Transformed Medicaid Statistical Information System, we found that the rate of continuous Medicaid enrollment during the twelve months postpartum increased from 59.3 percent for births during March-December 2018 to 90.7 percent for births during March-December 2020, when the public health emergency was in effect. This corresponds to approximately 430,000 fewer people losing Medicaid coverage after pregnancy and an average of more than 2.5 months of additional postpartum enrollment. These findings indicate that states that have extended or that plan to extend pregnancy-related Medicaid eligibility in the postpartum year are likely to experience significant gains in continuity of coverage.

Extended Postpartum Medicaid In Colorado Associated With Increased Treatment For Perinatal Mood And Anxiety Disorders.

Perinatal mood and anxiety disorders (PMAD), a leading cause of perinatal morbidity and mortality, affect approximately one in seven births in the US. To understand whether extending pregnancy-related Medicaid eligibility from sixty days to twelve months may increase the use of mental health care among low-income postpartum people, we measured the effect of retaining Medicaid as a low-income adult on mental health treatment in the postpartum year, using a "fuzzy" regression discontinuity design and linked all-payer claims data, birth records, and income data from Colorado from the period 2014-19. Relative to enrolling in commercial insurance, retaining postpartum Medicaid enrollment was associated with a 20.5-percentage-point increase in any use of prescription medication or outpatient mental health treatment, a 16.0-percentage-point increase in any use of prescription medication only, and a 7.3-percentage-point increase in any use of outpatient mental health treatment only. Retaining postpartum Medicaid enrollment was also associated with $40.84 lower out-of-pocket spending per outpatient mental health care visit and $3.24 lower spending per prescription medication for anxiety or depression compared with switching to commercial insurance. Findings suggest that extending postpartum Medicaid eligibility may be associated with higher levels of PMAD treatment among the low-income postpartum population.

Access to perinatal doula services in Medicaid: a case analysis of 2 states.

Doula services support maternal and child health, but few Medicaid programs reimburse for them. Through qualitative interviews with key policy informants (n = 20), this study explored facilitators and barriers to Medicaid reimbursement through perceptions of doula-related policies in 2 states: Oregon, where doula care is reimbursed, and Massachusetts, where reimbursement is pending. Five themes characterize the inclusion of doula services in Medicaid. In Theme 1, stakeholders recognized an imperative to expand access to doula services. Subsequent themes represent complications in accomplishing that imperative. In Theme 2, perceptions that doula services were not valued by health care providers resulted in conflict between doulas and the health care system. In Theme 3, complex billing processes created friction and impeded reimbursement. In Theme 4, internal conflict presented barriers to policymaking. In Theme 5, structural fragmentation between state government and doula communities was prominent in Massachusetts, presenting tensions during policymaking. Informants reported on problems demanding resolution to establish equitable and robust doula care policies. Medicaid coverage of doula services requires ongoing collaboration with doulas, providers, and health care advocates.

What is the role of selection bias in quality comparisons between the Veterans Health Administration and community care? Example of elective hernia surgery.

OBJECTIVE: To investigate the relationship between community care (CC) treatment and a postoperative surgical complication in elective hernia surgery among Veterans using multiple approaches to control for potential selection bias. DATA SOURCES AND STUDY SETTING: Veterans Health Administration (VHA) data sources included Corporate Data Warehouse (VHA encounters and patient data), the Program Integrity Tool and Fee tables (CC encounters), the Planning Systems Support Group (geographic information), and the Paid file (VHA primary care providers). STUDY DESIGN: Prior works suggest patient outcomes are better in VHA than in CC settings; however, these studies may not have appropriately accounted for the selection of higher-risk cases into CC. We estimated (1) a naïve logistic regression model to calculate the effect of CC setting on the probability of a complication, controlling for facility fixed effects and patient and procedure characteristics, and (2) a 2-stage model using the hernia patient's primary care provider's 1-year prior CC referral rate as the instrument. DATA COLLECTION: We identified patients residing ≤40 miles from a VHA surgical facility with elective VHA or CC hernia surgery from 2018 to 2019. PRINCIPAL FINDINGS: Of 7991 hernia surgeries, 772 (9.7%) were in CC. The overall complication rate was 4.2%; 286/7219 (4.0%) among VHA surgeries versus 51/5772 (6.6%, p < 0.05) in CC. We observed a 2.8 percentage point increase in the probability of postoperative complication given CC surgery (95% confidence interval: 0.7, 4.8) in the naïve model. After accounting for the VHA provider's historical rate of CC referral, we no longer observed a relationship between surgery setting and risk of postoperative complication. CONCLUSIONS: After accounting for the selection of higher-risk patients to CC settings, we found no difference in hernia surgery postoperative complications between CC and VHA. Future VHA and non-VHA comparisons should account for unobserved as well as observed differences in patients seen in each setting.

Medicaid Reimbursement for Doula Care: Policy Considerations From a Scoping Review.

Evidence suggests that perinatal doula care can support maternal health and reduce racial inequities among low-income pregnant and postpartum people, prompting growing interest by state Medicaid agencies to reimburse for doula services. Emerging peer-reviewed and gray literature document factors facilitating or impeding that reimbursement. We conducted a scoping review of that literature (2012-2022) to distill key policy considerations for policymakers and advocates in the inclusion of doula care as a Medicaid-covered benefit. Fifty-three reports met the inclusion criteria. Most (53%) were published in 2021 or 2022. Their stated objectives were advocating for expanded access to doula care (17%), describing barriers to policy implementation, and/or offering recommendations to overcome the barriers (17%). A primary policy consideration among states was prioritizing partnership with doulas and doula advocates to inform robust and equitable policymaking to sustain the doula profession.

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.

Differences Between VHA-Delivered and VHA-Purchased Behavioral Health Care in Service and Patient Characteristics.

OBJECTIVE: Federal legislation has expanded Veterans Health Administration (VHA) enrollees' access to VHA-purchased "community care." This study examined differences in the amount and type of behavioral health care delivered in VHA and purchased in the community, along with patient characteristics and area supply and demand factors. METHODS: This retrospective cross-sectional study examined data for 204,094 VHA enrollees with 448,648 inpatient behavioral health stays and 3,467,010 enrollees with 55,043,607 outpatient behavioral health visits from fiscal years 2016 to 2019. Standardized mean differences (SMDs) were calculated for patient and provider characteristics at the outpatient-visit level for VHA and community care. Linear probability models assessed the association between severity of behavioral health condition and site of care. RESULTS: Twenty percent of inpatient stays were purchased through community care, with severe behavioral health conditions more likely to be treated in VHA inpatient care. In the outpatient setting, community care accounted for 3% of behavioral health care visits, with increasing use over time. For outpatient care, veterans receiving community care were more likely than those receiving VHA care to see clinicians with fewer years of training (SMD=1.06). CONCLUSIONS: With a large portion of inpatient behavioral health care occurring in the community and increased use of outpatient behavioral health care with less highly trained community providers, coordination between VHA and the community is essential to provide appropriate inpatient follow-up care and address outpatient needs. This is especially critical given VHA's expertise in providing behavioral health care to veterans and its legislative responsibility to ensure integrated care.

Mental Health and Postpartum Care in California: Implications from California's Provisional Postpartum Care Extension.

BACKGROUND: California's Provisional Postpartum Care Extension (PPCE) extended Medicaid eligibility through 1 year postpartum for women enrolled in Medi-Cal with annual household incomes of 138%-322% of the federal poverty level and maternal mental health diagnoses. METHODS: For this cross-sectional descriptive study, we used the 2017 Listening to Mothers in California survey of postpartum women to identify those potentially eligible for PPCE. We then sought to describe their demographic characteristics, self-reported mental health, and utilization of postpartum care and mental health services compared with those with Medi-Cal during pregnancy who did not meet PPCE eligibility criteria. RESULTS: Overall, potentially PPCE-eligible women comprised 6.8% of respondents. Among those who did not qualify for PPCE, the primary reason was the absence of self-reported maternal mental health symptoms. Potentially PPCE-eligible women were approximately two-thirds Hispanic/Latina and more than one-third were ages 25 to 29. The most common self-reported mental health symptom was anxiety during pregnancy (78.9%). Among potentially PPCE-eligible women, 8.4% were taking medicine for anxiety/depression postpartum and 16.0% were receiving postpartum counseling/treatment for emotional or mental well-being. CONCLUSIONS: Our analyses suggest that PPCE could have extended postpartum coverage eligibility for approximately 30,360 women statewide. However, our findings demonstrate how narrowly defined PPCE eligibility criteria likely excluded many postpartum women in Medi-Cal who would have been left with limited benefits or more cost-sharing under alternative coverage options. This research could inform state and federal policymakers considering other proposals to extend postpartum Medicaid eligibility.

The Association Between Postpartum Insurance Instability and Access to Postpartum Mental Health Services: Evidence From Colorado.

INTRODUCTION: The objective of this study was to assess the association between postpartum insurance instability and access to postpartum mental health services. METHODS: We used 2018-2019 Colorado Health eMoms survey data, which sampled mothers from the 2018 birth certificate files at 3-6 months and 12-14 months postpartum. Respondents were classified as stably insured or unstably insured based on postpartum insurance status at each time point. We examined postpartum insurance patterns and used logistic regression to assess the association between postpartum insurance instability and mental health care access. RESULTS: Insurance changes primarily occurred by 3-6 months postpartum. Of respondents with public coverage at childbirth, 33.2% experienced postpartum insurance changes compared with 9.5% with private coverage (p < .001). Respondents who were younger, had incomes of less than $50,000, and were of Hispanic ethnicity were more likely to experience unstable postpartum insurance. Respondents who experienced postpartum insurance instability had a lower odds of reporting that they discussed mental health at a postpartum check-up (adjusted odds ratio, 0.4; 95% confidence interval, 0.2-0.7; p < .01) and received postpartum mental health services (adjusted odds ratio, 0.4; 95% confidence interval, 0.2-0.9; p < .05). CONCLUSIONS: The majority of postpartum insurance disruptions occurred among respondents with public coverage at childbirth and by 3-6 months postpartum. Respondents who experienced unstable coverage were more likely to have less access to postpartum mental health care. Policies that increase postpartum insurance stability, such as postpartum Medicaid extensions beyond 60 days, are needed to improve access to postpartum mental health services.