More extended health insurance coverage may increase postpartum visits, limit readmissions

Key takeaways:

• Comprehensive health insurance was linked to greater postpartum visit attendance.
• Florida’s mandatory Medicaid managed care policy was associated with lower rates of readmission and ED visits.

More comprehensive health insurance coverage may be associated with greater postpartum visit attendance and fewer preventable hospital readmissions and ED visits, according to a systematic review published in JAMA Network Open.

According to the researchers, recent estimates show that approximately 65% of pregnancy-related deaths in the U.S. occur during the first postpartum year, and about half of postpartum U.S. women do not receive routine postpartum health care.

“Currently, federal Medicaid coverage for pregnant individuals lapses after the last day of the month in which the 60th postpartum day occurs, which limits longer-term postpartum care. The American Rescue Plan Act of 2021 allowed states to request a waiver to extend postpartum Medicaid coverage up to 1 year after delivery,” Ian J. Saldanha, MBBS, MPH, PhD, associate professor of epidemiology at the Center for Clinical Trials and Evidence Synthesis at Johns Hopkins Bloomberg School of Public Health and epidemiologist and evidence-based researcher in the department of health services, policy and practice at Brown University School of Public Health, and colleagues wrote. “As of February 23, 2023, 28 states and the District of Columbia have implemented the approved extensions, seven states are planning extensions, three states are seeking federal approvals through waivers and two states have proposed limited coverage extensions. Extended coverage for approved states began on April 1, 2022, and is intended to run for 5 years.”

Saldanha and colleagues searched MEDLINE, Embase, CENTRAL, CINAHL and ClinicalTrials.gov for U.S.-based studies from inception to November 2022. Researchers identified 28 mostly moderate risk of bias nonrandomized comparative studies that included 3,423,781 participants published from 2008 to 2022 for systematic review and assessed the strength of evidence in all studies using the Agency for Healthcare Research and Quality’s methods guide.

Four studies addressed insurance type, 13 addressed policy changes making insurance more comprehensive, two addressed policy changes making insurance less comprehensive and nine addressed Medicaid expansion.

Eleven studies reported data on postpartum visit attendance, and eight reported that more comprehensive health insurance was associated with greater attendance with moderate strength of evidence. One study reported a higher number of postpartum visits per patient by 3 months when comparing before and after a North Carolina Medicaid policy that reduced reimbursement for maternity care by 19% (P < .001). In another study, researchers reported more outpatient postpartum visits per patient in a Medicaid expansion state compared with a non-expansion state by 3 (P < .001) and 6 (P < .01) months with a greater mean number of visits among participants with severe maternal morbidity.

One study with low strength of evidence reported on unplanned health care utilization and found that Florida’s mandatory Medicaid managed care policy was associated with lower rates of preventable hospital readmission (incidence rate ratio [IRR] = 0.86; 95% CI, 0.8-0.93) and ED visits (IRR = 0.87; 95% CI, 0.82-0.93) by 1.5 months postpartum.

“Future research should evaluate the impact of more comprehensive or extended health insurance on health outcomes in the postpartum period and beyond,” the researchers wrote. “Researchers should report separate data for various population subgroups, so that decision-makers can understand the implications of health insurance extension for different populations.”