Citizenship status may prevent women living in some states from accessing prenatal care

In states where Medicaid policies exclude immigrants, Asian and Hispanic women were less likely to have access to prenatal care in the first trimester, according to findings published in JAMA Network Open.

“Noncitizens face many obstacles to obtaining health coverage both during and outside of pregnancy,” Ashley M. Fox, PhD, MA, an associate professor of public administration and policy at the State University of New York at Albany, said in a press release. “The pathways available for immigrants to access care are often complex and vary based on qualifying status, time in the country, and state or locality of residence. Recent policy changes that have extended Medicaid eligibility, both prior to and during the COVID-19 pandemic, have often excluded immigrants either inadvertently or advertently.”

Defining methods, cohort

Fox and colleagues used U.S. natality data to cross-sectionally analyze 11,935,806 singleton births that occurred between 2011 and 2019 in 31 states. Of these states, 16 expanded Medicaid eligibility as part of the 2014 Affordable Care Act.

The researchers compared the rate of access to prenatal care during the first trimester — termed timely prenatal care — before and after Medicaid expansion in states that underwent expansion. They also compared the rates of access in states that did vs. did not expand Medicaid eligibility.

In total, 5,390,814 women who delivered before Medicaid expansion and 6,544,992 women who delivered after expansion were included in analyses. In states that expanded their Medicaid programs, 413,479 (27.3%) immigrants were Asian, 110,829 (7.3%) were Black, 752,176 (49.6%) were Hispanic and 238,746 (15.8%) were white. Among U.S.-born women in these states, 96,807 (2.5%) were Asian, 470,128 (12.1%) were Black, 699,776 (18.1%) were Hispanic and 2,608,873 (67.3%) were white.

Access in states with expanded Medicaid coverage

Prior to expansion, immigrant women were less likely to have access to timely prenatal care in states that later expanded their Medicaid programs compared with U.S.-born women (75.9% vs. 79.9%; adjusted difference, –3.48 per 100 women; 95% CI, –6.95 to –0.01). After expansion, the disparity between immigrants and U.S.-born women widened (77.9% vs. 82.7%; adjusted difference, –4.39 per 100 women; 95% CI, –7.07 to –1.71; difference-in-difference [DID], –0.91; 95% CI, –1.91 to 0.09).

Analyses by race and ethnicity revealed increased disparities in timely prenatal care access for immigrant women after Medicaid expansion among Asian women (DID, –1.53 per 100 women; 95% CI, –2.31 to –0.75) and Hispanic women (DID, –1.18 per 100 women; 95% CI, –2.07 to –0.3). There were no significant differences in disparities pre- and post-expansion among Black and white women.

Having a high school education or less was associated with greater disparities after Medicaid expansion. The DID was –2.98 per 100 women (95% CI, –4.45 to –1.51) among Asian women and –1.47 per 100 women (95% CI, –2.48 to –0.46) among Hispanic women.

Access in states with no Medicaid expansion

Compared with states that expanded their Medicaid eligibility, an additional 1.41 per 100 Hispanic immigrants did not have access to timely prenatal care in states that did not expand their Medicaid eligibility (95% CI, –2.89 to –0.07). Again, lower educational attainment was associated with greater differences (triple difference, –1.86; 95% CI, –3.31 to –0.42).

Differences in access between states that did and did not expand their programs were not significant for any other races or ethnicities.

“Our study shows that immigrant exclusions to Medicaid eligibility may exacerbate disparities,” Teresa Janevic, PhD, MPH, an associate professor in the departments of obstetrics, gynecology and reproductive science, population health science and policy and global health and health systems design at Icahn School of Medicine at Mount Sinai, said in the release. “Prompt and appropriate access to prenatal care is important because it benefits mothers and infants beyond pregnancy and birth. We know insurance coverage prior to pregnancy results in an earlier start to prenatal care; therefore, Medicaid coverage before pregnancy is an important lever to improve timely prenatal care.”

References:

• Janevic T, et al. JAMA Netw Open. 2022;doi:10.1001/jamanetworkopen.2022.39264.
• Study finds persistent disparities in access to prenatal care among pregnant people based on citizenship status and education level. https://www.mountsinai.org/about/newsroom/2022/study-finds-persistent-disparities-in-access-to-prenatal-care-among-pregnant-people-based-on-citizenship-status-and-education-level. Published Oct. 28, 2022. Accessed Nov. 4, 2022.