Association of the Affordable Care Act Dependent Coverage Provision With Prenatal Care Use and Birth Outcomes

Daw, Jamie R.; Sommers, Benjamin D.

doi:10.1001/jama.2018.0030

Cited by 52 publications

(27 citation statements)

References 38 publications

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“…There is limited research on this association among women with commercial health insurance, who account for almost half of all births [18]. The proportion of births covered by commercial health insurance, particularly after the implementation of the Affordable Care Act (ACA), is growing [38,39]. This study showed that despite access to commercial health insurance coverage, women who resided in areas with higher deprivation were at greater odds of preterm birth.…”

Section: Strengths and Limitationsmentioning

confidence: 95%

Area-level deprivation and preterm birth: results from a national, commercially-insured population

Mehra¹,

Shebl

Cunningham³

et al. 2019

BMC Public Health

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Background: Area-level deprivation is associated with multiple adverse birth outcomes. Few studies have examined the mediating pathways through which area-level deprivation affects these outcomes. The objective of this study was to investigate the association between area-level deprivation and preterm birth, and examine the mediating effects of maternal medical, behavioural, and psychosocial factors. Methods: We conducted a retrospective cohort study using national, commercial health insurance claims data from 2011, obtained from the Health Care Cost Institute. Area-level deprivation was derived from principal components methods using ZIP code-level data. Multilevel structural equation modeling was used to examine mediating effects. Results: In total, 138,487 women with a live singleton birth residing in 14,577 ZIP codes throughout the United States were included. Overall, 5.7% of women had a preterm birth. In fully adjusted generalized estimation equation models, compared to women in the lowest quartile of area-level deprivation, odds of preterm birth increased by 9.6% among women in the second highest quartile (odds ratio (OR) 1.096; 95% confidence interval (CI) 1.021, 1.176), by 11.3% in the third highest quartile (OR 1.113; 95% CI 1.035, 1.195), and by 24.9% in the highest quartile (OR 1.249; 95% CI 1.165, 1.339). Hypertension and infection moderately mediated this association. Conclusions: Even among commercially-insured women, area-level deprivation was associated with increased risk of preterm birth. Similar to individual socioeconomic status, area-level deprivation does not have a threshold effect. Implementation of policies to reduce area-level deprivation, and the screening and treatment of maternal mediators may be associated with a lower risk of preterm birth.

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Section: Strengths and Limitationsmentioning

confidence: 95%

Area-level deprivation and preterm birth: results from a national, commercially-insured population

Mehra¹,

Shebl

Cunningham³

et al. 2019

BMC Public Health

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“…Although the ACA did not alter Medicaid coverage during pregnancy [32], we found that the ACA's Medicaid expansion was associated with a significant increase in medications for OUD among pregnant women with a criminal justice agency or individual referral in expansion states compared with nonexpansion states. There are several possible explanations for this finding.…”

Section: Plos Medicinementioning

confidence: 62%

Medications for opioid use disorder among pregnant women referred by criminal justice agencies before and after Medicaid expansion: A retrospective study of admissions to treatment centers in the United States

et al. 2020

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BackgroundCriminal justice involvement is common among pregnant women with opioid use disorder (OUD). Medications for OUD improve pregnancy-related outcomes, but trends in treatment data among justice-involved pregnant women are limited. We sought to examine trends in medications for OUD among pregnant women referred to treatment by criminal justice agencies and other sources before and after the Affordable Care Act's Medicaid expansion. Methods and findingsWe conducted a serial, cross-sectional analysis using 1992-2017 data from pregnant women admitted to treatment facilities for OUD using a national survey of substance use treatment facilities in the United States (N = 131,838). We used multiple logistic regression and difference-in-differences methods to assess trends in medications for OUD by referral source. Women in the sample were predominantly aged 18-29 (63.3%), white non-Hispanic, high school graduates, and not employed. Over the study period, 26.3% (95% CI 25.7-27.0) of pregnant women referred by criminal justice agencies received medications for OUD, which was significantly less than those with individual referrals (adjusted rate ratio [ARR] 0.45, 95% CI 0.43-0.46; P < 0.001) or those referred from other sources (ARR 0.51, 95% CI 0.50-0.53; P < 0.001). Among pregnant women referred by criminal justice agencies, receipt of medications for OUD increased significantly more in states that expanded

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“…Current literature examining the influence of nonpregnancy Medicaid expansion on maternal health care use in the overall population has mixed findings. 23 , 24 , 25 , 26 , 27 , 28 Our analysis builds on this research with a new focus on a large proportion of birthing individuals not eligible for Medicaid in most areas in the US.…”

Section: Discussionmentioning

confidence: 99%

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

et al. 2022

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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.

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Association of the Affordable Care Act Dependent Coverage Provision With Prenatal Care Use and Birth Outcomes

Cited by 52 publications

References 38 publications

Area-level deprivation and preterm birth: results from a national, commercially-insured population

Area-level deprivation and preterm birth: results from a national, commercially-insured population

Medications for opioid use disorder among pregnant women referred by criminal justice agencies before and after Medicaid expansion: A retrospective study of admissions to treatment centers in the United States

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

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