Association of Medicaid Expansion With Neuraxial Labor Analgesia Use in the United States: A Retrospective Cross-Sectional Analysis

Abstract

BACKGROUND: The Affordable Care Act has been associated with increased Medicaid coverage for childbirth among low-income US women. We hypothesized that Medicaid expansion was associated with increased use of labor neuraxial analgesia. METHODS: We performed a cross-sectional analysis of US women with singleton live births who underwent vaginal delivery or intrapartum cesarean delivery between 2009 and 2017. Data were sourced from births in 26 US states that used the 2003 Revised US Birth Certificate. Difference-in-difference linear probability models were used to compare changes in the prevalence of neuraxial labor analgesia in 15 expansion and 11 nonexpansion states before and after Medicaid expansion. Models were adjusted for potential maternal and obstetric confounders with standard errors clustered at the state level. RESULTS: The study sample included 5,703,371 births from 15 expansion states and 5,582,689 births from 11 nonexpansion states. In the preexpansion period, the overall rate of neuraxial analgesia in expansion and nonexpansion states was 73.2% vs 76.3%. Compared with the preexpansion period, the rate of neuraxial analgesia increased in the postexpansion period by 1.7% in expansion states (95% CI, 1.6–1.8) and 0.9% (95% CI, 0.9–1.0) in nonexpansion states. The adjusted difference-in-difference estimate comparing expansion and nonexpansion states was 0.47% points (95% CI, −0.63 to 1.57; P = .39). CONCLUSIONS: Medicaid expansion was not associated with an increase in the rate of neuraxial labor analgesia in expansion states compared to the change in nonexpansion states over the same time period. Increasing Medicaid eligibility alone may be insufficient to increase the rate of neuraxial labor analgesia.

Association of the United States Affordable Care Act Dependent Coverage Provision with Labor Neuraxial Analgesia Use

“…reported that the Medicaid expansion was associated with a 1.5% (95% CI, 0.2 to 2.9) increase in the labor neuraxial analgesia utilization rate among nulliparous women in states that expanded Medicaid compared to nulliparous women in states that did not expand Medicaid. 28 This effect size is similar to the one observed in our study, and although statistically significant, is also unlikely of clinical significance.…”

“…For example, a regression coefficient of 0.012 indicates that the Dependent Coverage provision is associated with a 1.2% (absolute) increase in the probability of labor neuraxial analgesia in women aged 21 to 25 yr compared to women aged 27 to 31 yr. †Adjustment used the following variables: (1) race and ethnicity, (2) education level, (3) marital status, (4) county of residence core base statistical area classification, (5) county of residence percent persons in poverty, (6) county of residence percent unemployed, (7) prepregnancy body mass index, (8) preexisting diabetes, (9) gestational diabetes, (10) preexisting hypertension, (11) gestational hypertension, (12) previous cesarean section, (13) Analyzing birth certificate data, Xiao et al reported that the Medicaid expansion was associated with a 1.5% (95% CI, 0.2 to 2.9) increase in the labor neuraxial analgesia utilization rate among nulliparous women in states that expanded Medicaid compared to nulliparous women in states that did not expand Medicaid. 28 This effect size is similar to the one observed in our study, and although statistically significant, is also unlikely of clinical significance.…”

“…27 Previous research on the association of provision of health insurance coverage with labor neuraxial analgesia use is limited to one study by Xiao et al on the 2014 Medicaid expansion authorized by the Patient Protection and Affordable Care Act. 28 The 2014 Medicaid expansion led to a significant reduction in insurance discontinuity for pregnant people, and to an increase in preconception, prenatal, and postpartum healthcare access and utilization. 10,11 *the difference-in-differences estimator is the regression coefficient of a two-way interaction term between the age group (indicator of the 21-to 25-yr-old group) and the period (indicator of the postintervention period) in a linear regression model.…”

Closing the Knowledge Translation Gap: Health Services Research and Perioperative Medicine—New Horizons for Anesthesiologists

“…13 Several of the articles in this issue have used large databases appropriately to report on diverse topics spanning from coronavirus disease 2019 (COVID-19), the impact of Medicaid expansion on the use of neuraxial labor analgesia, and the association between changes in postoperative opioid utilization and longterm health care spending among surgical patients with chronic opioid utilization. [14][15][16] The paper by Sun 16 examining opioid utilization highlights the important evolving area of value-based care and the triple aim. Porter 17 defined value in health care as the quality of outcomes achieved over spent costs.…”

“…13 Several of the articles in this issue have used large databases appropriately to report on diverse topics spanning from coronavirus disease 2019 (COVID-19), the impact of Medicaid expansion on the use of neuraxial labor analgesia, and the association between changes in postoperative opioid utilization and long-term health care spending among surgical patients with chronic opioid utilization. 14–16…”