Analysis of State Medicaid Expansion and Access to Timely Prenatal Care Among Women Who Were Immigrant vs US Born

Abstract

ImportanceDisparities exist in access to timely prenatal care between immigrant women and US-born women. Exclusions from Medicaid eligibility based on immigration status may exacerbate disparities.ObjectiveTo examine changes in timely prenatal care by nativity after Medicaid expansion.Design, Setting, and ParticipantsA cross-sectional difference-in-differences (DID) and triple-difference analysis of 22 042 624 singleton births from January 1, 2011, to December 31, 2019, in 31 states was conducted using US natality data. Data analysis was performed from February 1, 2021, to August 24, 2022.ExposuresWithin 16 states that expanded Medicaid in 2014, the rate of timely prenatal care by nativity in years after expansion was compared with the rate in the years before expansion. Similar comparisons were conducted in 15 states that did not expand Medicaid and tested across expansion vs nonexpansion states.Main Outcomes and MeasuresTimely prenatal care was categorized as prenatal care initiated in the first trimester. Individual-level covariates included age, parity, race and ethnicity, and educational level. State-level time-varying covariates included unemployment, poverty, and Immigrant Climate Index.ResultsA total of 5 390 814 women preexpansion and 6 544 992 women postexpansion were included. At baseline in expansion states, among immigrant women, 413 479 (27.3%) were Asian, 110 829 (7.3%) were Black, 752 176 (49.6%) were Hispanic, and 238 746 (15.8%) were White. Among US-born women, 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. Prenatal care was timely in 75.9% of immigrant women vs 79.9% of those who were US born in expansion states at baseline. After Medicaid expansion, the immigrant vs US-born disparity in timely prenatal care was similar to the preexpansion level (DID, –0.91; 95% CI, –1.91 to 0.09). Stratifying by race and ethnicity showed an increase in the Asian vs White disparity after expansion, with 1.53 per 100 fewer immigrant women than those who were US born accessing timely prenatal care (95% CI, –2.31 to –0.75), and in the Hispanic vs White disparity (DID, –1.18 per 100; 95% CI, –2.07 to –0.30). These differences were more pronounced among women with a high school education or less (DID for Asian women, –2.98; 95% CI, –4.45 to –1.51; DID for Hispanic women, –1.47; 95% CI, –2.48 to –0.46). Compared with nonexpansion states, differences in DID estimates were found among Hispanic women with a high school education or less (triple-difference, –1.86 per 100 additional women in expansion states who would not receive timely prenatal care; 95% CI, –3.31 to –0.42).Conclusions and RelevanceThe findings of this study suggest that exclusions from Medicaid eligibility based on immigration status may be associated with increased health care disparities among some immigrant groups. This finding has relevance to current policy debates regarding Medicaid coverage during and outside of pregnancy.

Left Behind: Medicaid Immigrant Exclusions and Access to Maternal Health Care Across the Reproductive-Perinatal Continuum

“…An estimated 10.5 million immigrants are undocumented, constituting nearly a quarter (23%) of all immigrants (Budiman, 2020). These groups remain subject to exclusion from the Medicaid expansions following the Affordable Care Act (ACA) implementation (Janevic et al, 2022). These same structural barriers have excluded these groups from health care extensions throughout the COVID-19 pandemic.…”

“…Federal policy restricting immigrant access to public health insurance through Medicaid, may contribute to elevated maternal health risk and maternal health inequities. Many categories of immigrants were “left behind” from the Medicaid expansion under the Affordable Care Act (Janevic et al, 2022). Existing state Medicaid policies excluding different categories of immigrants threaten to further “leave behind” immigrants from new and future Medicaid coverage expansions, such as pending postpartum Medicaid extensions from 2 months to 12 months (Janevic et al, 2022).…”

“…Many categories of immigrants were “left behind” from the Medicaid expansion under the Affordable Care Act (Janevic et al, 2022). Existing state Medicaid policies excluding different categories of immigrants threaten to further “leave behind” immigrants from new and future Medicaid coverage expansions, such as pending postpartum Medicaid extensions from 2 months to 12 months (Janevic et al, 2022). Researchers are increasingly discussing stratification in access to care by the degree of legality and citizenship entitlement as a form of structural racism (Acevedo-Garcia et al, 2021).…”

Insurance coverage and discontinuity during pregnancy: Frequency and associations documented in the PROMISE cohort

“…15 On the other hand, some state Medicaid policies exclude people based on immigration status, such as unauthorized immigrants, legal permanent residents, and those with legal status for fewer than 5 years. 16,17 In 2021, Medicaid covered 41.0% of all US births. 18 The existence of health insurance discontinuities (i.e., "churn") around childbirth is well-documented.…”

“…18 Uninsurance despite aforementioned insurance policies is likely driven, in part, by eligibility restrictions for Medicaid based on immigration status. 16,17 Pregnancy and childbirth are time periods in which timely health care access is strongly related to health outcomes. For example, inadequate prenatal health care is associated with an increased risk of prematurity, stillbirth, neonatal death, and infant death (although specific mechanisms require elucidation).…”