Expanding Medicaid can improve birth outcomes

Earlier this week, Michigan Governor Rick Snyder signed legislation that accepts the Affordable Care Act’s Medicaid expansion for his state, and Pennsylvania Governor Tom Corbett has signaled his intention to do so if the federal government approves his proposed program changes. Wonkblog’s Sarah Kliff notes that if Pennsylvania does expand its Medicaid program, that will mean the majority of the states have adopted one of the main aspects of the Affordable Care Act. This is good news for the millions of low-income uninsured US residents who will gain health coverage from Medicaid.

Another recent headline comes from a study, published in the journal Women’s Health Issues, reporting that nearly half of all US births (48%) in 2010 were covered by Medicaid. (Disclosure: Three of the study authors are from the George Washington University School of Public Health, where I work.) This is up from a previous estimate of 45% of all births, and it emphasizes the importance of Medicaid’s role in public health. The authors (Markus et al) note, “As states expand coverage to low-income women, women of childbearing age will be able to obtain coverage before and between pregnancies, allowing for access to services that could improve their overall and reproductive health as well as birth outcomes.” I hope governors and legislators in the 24 states that haven’t yet accepted the expansion will keep this in mind as they consider the future of their Medicaid programs.

First, some background: The Affordable Care Act, also known as Obamacare, has two main mechanisms to help those who are uninsured get affordable health insurance. First, it expands eligibility for Medicaid to citizens and legal residents of 5+ years who have incomes of up to 133% of the federal poverty level, and the federal government will cover 100% of the costs of this expansion initially and no less than 90% in all future years. (Generally, the federal government covers 50 – 75% of Medicaid beneficiaries’ healthcare costs; percentages vary depending on states’ economic circumstances.) Second, the ACA establishes state health insurance exchanges, or marketplaces, where all legal US residents can buy individual coverage and those with incomes of 100-400% FPL can get sliding-scale subsidies toward premiums. The Supreme Court made this all a lot more complicated when it decided that the Medicaid expansion portion of the law would be optional for states.

People eligible for coverage under the Medicaid expansion are far from wealthy: In 2013, the federal poverty level is $11,460 for a one-person family (133% is $15,282), and $23,550 for a four-person family (133% is $31,322).

Medicaid and women of childbearing age
In order to get federal funds for their Medicaid programs, states have long been required to cover certain populations, including pregnant women and children up through age five with family incomes of up to 133% of the federal poverty level, children ages 6 – 18 with family incomes of up to 100% FPL, and low-income adults with dependent children (income cutoff limits for this group vary by state). Many states have expanded eligibility beyond the federal minimums; in the case of pregnant women, 19 states and the District of Columbia will enroll women with incomes of up to 185% FPL; 15 states have cutoffs of 200 – 299% FPL, and Iowa and Wisconsin allow pregnant women with incomes of up to 300% FPL to enroll in Medicaid. All women who become eligible for Medicaid based on pregnancy status retain the coverage for 60 days after giving birth.

Before becoming pregnant and after 60 days post-partum, though, it’s often hard for non-disabled low-income women under age 65 to get Medicaid coverage. Only eight states and the District of Columbia offer full Medicaid coverage to childless adults, and income cutoffs for parents of dependent children have a median of 61% for working parents and 37% for non-working parents. Several states have used Medicaid waivers and federal Title X funds to offer family-planning services and pre-conception or inter-conception care to low-income women, and some states have used waivers to extend Medicaid coverage to women who lose it after a baby’s birth or an increase in family income.

The ACA's Medicaid expansion does not address the health of undocumented immigrant women or those who have been in the US legally for fewer than five years, who are ineligible for Medicaid coverage. Strict requirements for proof of legal status can also pose a barrier to enrollment for women who are eligible but have difficulty obtaining the required documentation. Some states use their own funds to cover women who do not meet federal requirements for immigration status or documentation.

Women’s health and birth outcomes
It’s in states’ interest to cover pregnant women, so that they can have access to prenatal care that can contribute to healthy babies -- but women's health and healthcare prior to conception also matters. “Rising rates of maternal mortality, stagnant rates of infant mortality, high proportions of preterm and low birthweight births, and continuing disparities in pregnancy outcomes in the United States have prompted a number of states to increase their focus on the health risks faced by women of childbearing age,” reports Kay Johnson in a 2012 Commonwealth Fund issue brief. These risks include chronic health conditions such as diabetes and hypertension; smoking and heavy alcohol use; and depression, all of which disproportionately affect low-income women and women of color, Johnson notes. Treating these conditions prior to conception can improve pregnancy outcomes, as well as women’s overall health.

Birth spacing is another important factor in birth outcomes. Short intervals between pregnancies are associated with increased risks for preterm birth and for low birthweight in babies, and for preeclampsia in mothers. The 2020 Healthy People goals include reducing the number of pregnancies occurring within 18 months after giving birth, and recent research has found short birth spacing to be strongly linked to unintended pregnancies. Ensuring that women have access to contraception and medical guidance can allow for birth spacing that's favorable to the health of both mothers and children.

In 2006, the Institute of Medicine sounded the alarm about the growing public health problem of preterm births (those occurring before 37 weeks of gestation). Preterm babies are at higher risk for health and developmental problems than their full-term counterparts, and the IOM committee estimated that costs for medical care and disability associated with US preterm births top $26 billion per year.  Reducing preterm births could result in substantial savings as well as improved quality of life.

Ideally, everyone would have access to the healthcare services they need to be in optimum health; given limited healthcare dollars, though, it makes sense to target them at women whose health will most directly influence the health of the next generation.  And given that nearly half of all US pregnancies are unplanned, the best way to ensure that women have access to healthcare services prior to conceiving is to ensure that all women of childbearing age have access to healthcare.

Care from community health centers
Being insured isn’t necessarily synonymous with having access to healthcare, although in the US people with health insurance have better health outcomes than those without. Community health centers – also known as federally qualified health centers, or FQHCs – have long been a source of high-quality, affordable primary healthcare for low-income and uninsured individuals. In a 2008 article in Women’s Health Issues, Sara Wilensky and Michelle Proser describe how health centers deliver preconception care and how their low-income patients have better birth outcomes than low-income US women as a whole:

Almost 60% of health center patients are women, about half of whom are women of childbearing age. In addition, health centers provide care for >17% of low-income births in the United States. Most health centers offer their patients preconception services, such as HIV/AIDS screening and treatment, weight management, nutrition counseling, and smoking cessation programs, in addition to comprehensive primary care services. Three quarters of health centers provide mental health services and half provide substance abuse treatment services onsite; the rest provide these services in partnership with other providers. Health centers also participate in a number of community-based programs focused on improving women’s health and providing preconception care services.

... Low socioeconomic status (SES) women seeking care at health centers experience lower rates of low birth weight (LBW) babies compared with all low-SES mothers (7.5% vs. 8.2%), a trend that holds for each racial/ethnic group. This is particularly noteworthy for African American women of low SES who are especially at higher risk for adverse pregnancy outcomes. If the LBW black–white disparity seen at health centers could be achieved nationally, there would be 17,100 fewer LBW black infants annually (Shi et al., 2004).

Health centers are also a major source of primary care for Medicaid beneficiaries; in 2012, 40% of health center patients had Medicaid or CHIP coverage. Another 36% were uninsured. Health centers receive federal grants that help cover the cost of caring for uninsured patients, but they also rely heavily on Medicaid revenue. In recognition of the comprehensive care health centers provide (including nutritional counseling, case management, and translation services), health centers receive higher Medicaid payments than other providers. States’ decisions about accepting the Medicaid expansion will greatly affect the finances of their health centers – which in turn affects low-income women’s access to high-quality preconception and prenatal care.

The states that have not yet accepted the Medicaid expansion need to keep in mind that their decisions affect not only the health of their poorest residents, but of the next generation.