Continuous Medicaid eligibility during COVID-19 increased postpartum coverage

Key takeaways:

• Increasing state Medicaid eligibility during COVID-19 prevented loss in Medicaid coverage after delivery for white and Black women.
• Hispanic women saw no reductions in Medicaid loss with this policy.

Continuous Medicaid eligibility during COVID-19 significantly reduced postpartum loss of insurance, but was not tied to health care use, contraceptive use, breastfeeding or depressive symptoms in early postpartum, researchers reported.

“To improve postpartum coverage for Medicaid beneficiaries, the 2021 American Rescue Plan Act (ARPA) offered a new state option to use federal matching funds to extend pregnancy-related Medicaid eligibility to 1 year postpartum. As of January 2024, 43 states and Washington, D.C., had adopted this option,” Jamie R. Daw, PhD, assistant professor in the department of health policy and management at Columbia University Mailman School of Public Health, and colleagues wrote. “COVID-19 pandemic response legislation could provide early insight into the potential effect of post-pandemic ARPA extensions. The 2020 Families First Coronavirus Response Act (FFCRA) included a maintenance of effort requirement preventing states from disenrolling Medicaid recipients during the federal public health emergency from Jan. 31, 2020, to May 11, 2023. This created a de facto national extension of pregnancy-related Medicaid eligibility.”

Daw and colleagues conducted a cohort study, published in JAMA Health Forum, utilizing data from the CDC Pregnancy Risk Assessment Monitoring System (PRAMS) from 2017 to 2021. Of the 21 included states, FFCRA-associated postpartum Medicaid income eligibility increases ranged from 24% to 206% of the federal poverty level, with a median increase of 82%, which was similar to the median increase of 85% for all 50 states plus Washington, D.C. Researchers estimated associations between state-level changes in Medicaid income eligibility and changes in health insurance, postpartum visit attendance, contraceptive use, breastfeeding and depressive symptoms measured at a mean of 4 months postpartum during the post-policy period (2020-2021) compared with the pre-policy period (2017-2019).

Overall, 47,716 respondents from PRAMS who had a Medicaid-paid delivery were included, of whom 64.4% were younger than 30 years and 22.5% reported at least one chronic condition. Of these women, 36.3% were non-Hispanic white, 26.2% were non-Hispanic Black, 18.9% were Hispanic and 18.6% were of other races/ethnicities.

In adjusted models, a Medicaid income eligibility increase to 100% of the federal poverty level was associated with a 5.1 percentage point increase in reported postpartum Medicaid coverage, which represented an 8.1% increase from pre-policy baseline. In addition, an income eligibility increase to 100% of the federal poverty level was associated with a 6.6 percentage point decrease in Medicaid loss, which represented a 40% reduction from the pre-policy baseline of 16.7%.

In exploratory subgroup analyses by race and ethnicity, loss of Medicaid coverage after a Medicaid-paid delivery was reduced by 96.9% from baseline among Black women and 69.3% among white women, but no change was observed among Hispanic women.

Researchers observed no significant associations between the FFCRA and postpartum health care use, contraception use, breastfeeding or depressive symptoms in the early postpartum period.

“These findings, though potentially shaped by the COVID-19 pandemic and the fact that this policy was not tailored to postpartum people, may offer preliminary insights into the potential effects of post-pandemic postpartum Medicaid eligibility extensions,” the researchers wrote. “More robust outcome data on health care use and well-being with longer-term follow-up in the postpartum year is urgently needed to inform and evaluate ongoing state adoption and implementation of postpartum Medicaid extensions.”