Transitions in Health Insurance During the Perinatal Period Among Patients With Continuous Insurance Coverage

Abstract

ImportanceAlthough health insurance continuity is important during the perinatal period to improve birth outcomes and reduce maternal morbidity and mortality, insurance disruptions are common. However, little is known about insurance transitions among insurance types for individuals who remained insured during the perinatal period.ObjectiveTo examine insurance transitions for birthing individuals with continuous insurance, including those with Medicaid and Medicaid managed care coverage, before, during, and after pregnancy.Design, Setting, and ParticipantsThis cohort study used January 1, 2014 to December 31, 2018 data from the Massachusetts All-Payer Claims Database. The sample included deliveries from January 1, 2015, to December 31, 2017, to birthing individuals aged 18 to 44 years old with continuous insurance for 12 months before and after delivery. Data were analyzed from November 9, 2021, to September 2, 2022.ExposureInsurance type at delivery.Main Outcomes and MeasuresThe primary outcome was a binary indicator of any transition in insurance type from 12 months before and/or after delivery. The secondary outcomes were measures of any predelivery transition (12 months before delivery month) and any transition during the postpartum period (delivery month to 12 months post partum). Multivariate logit regression models were used to analyze the association of an insurance transition in the perinatal period with insurance type in the delivery month, controlling for age and socioeconomic status based on a 5-digit zip code.ResultsThe analytic sample included 97 335 deliveries (mean [SD] maternal age at delivery, 30.4 [5.5] years). Of these deliveries, 23.4% (22 794) were insured by Medicaid and 28.1% (27 347) by Medicaid managed care in the delivery month. A total of 37.1% of the sample (36 127) had at least 1 insurance transition during the 12 months before and/or after delivery. In regression-adjusted analyses, those individuals covered by Medicaid and Medicaid managed care at delivery were 47.0 (95% CI, 46.3-47.7) percentage points and 50.1 (95% CI, 49.4-50.8) percentage points, respectively, more likely to have an insurance transition than those covered by private insurance. Those covered by Marketplace plans at delivery had a 33.1% (95% CI, 31.4%-34.8%) regression-adjusted predicted probability of having a postpartum insurance transition.Conclusions and RelevanceResults of this study showed that insurance transitions during the perinatal period occurred for more than 1 in 3 birthing individuals with continuous insurance and were more common among those with Medicaid or Medicaid managed care at delivery. Further research is needed to examine the role of insurance transitions in health care use and outcomes during the perinatal period.

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

“…In contrast, this study used repeated measures of the payer billed at the time of care delivery and/or payment, which removes issues of self‐report and historical recall, and also provides longitudinal data to directly document insurance discontinuity. Perhaps for this reason, our estimate of insurance churn is closer in magnitude to findings from a recent study (14.4%) using the Massachusetts All‐Payer Claims Database to classify insurance transitions in the 12 months before delivery among those with continuous insurance (e.g., transitions between private insurance and Medicaid) 20 …”

“…Studies using cross-sectional and self-reported data have reported the presence of insurance discontinuities during pregnancy, 8,9,12,13,19 and one study has used provider-recorded longitudinal data to enumerate transitions in continuous insurance. 20 Our study is the first to use provider-recorded longitudinal data that includes uninsured individuals to detail the timing and nuances of insurance churn. We report a lower prevalence of insurance churn (16.6%) than previous work that used MEPS-HC (58%) 8 or PRAMS (30.1% 9 and 48.7% 19 ) data.…”

“…18 The existence of health insurance discontinuities (i.e., "churn") around childbirth is well-documented. 8,9,12,13,19,20 Prior work has demonstrated that approximately 30% of birthing people in 2009 experienced changes in health insurance coverage during pregnancy. 9 Perinatal churn is more common among people with lower income: 83.8% of those who experienced changes in health insurance coverage during pregnancy had incomes ≤200% FPL.…”

Maternity care clinician inclusion in Medicaid Accountable Care Organizations

“…Another study found 96% of mothers cited accepting their health insurance plan as a major factor when choosing a prenatal care provider and birth hospital [18,19]. Understanding inclusion of providers and overlap among Medicaid ACOs is particularly important given ongoing transitions in insurance plans, including among those insured by Medicaid, during the perinatal period [20]. Obstetrician-gynecologists (OB/GYNs) are uniquely placed as physicians because they provide preventive services and act as primary care providers for some patients and 25% of women consider their OB/GYN to be their primary care provider; however, they do not always provide the full range of preventive services offered by family physicians and internists, and have not been used to build primary care-focused ACOs [21][22][23][24][25][26].…”

Error in the Results Section

“…The sentence should state “Among individuals who transitioned from Medicaid, 64.3% switched to Medicaid managed care.” The article has been corrected. 1 …”