Racial Inequities in Postpartum Coverage During Medicaid Continuous Coverage: Evidence From Affordable Care Act Expansion Versus Nonexpansion States.

Abstract

Extending pregnancy Medicaid coverage to 12 months after delivery is a key strategy to reduce maternal morbidity and mortality and may be most impactful among states that did not expand Medicaid as part of the Affordable Care Act. The continuous Medicaid coverage provision enacted at the onset of the COVID-19 pandemic provides a natural experiment to test the impact of postpartum Medicaid extension policies. A cross-sectional pre-post design was used to estimate changes in postpartum insurance after the introduction of continuous Medicaid coverage. Using 2016-2023 American Community Survey data, non-Hispanic Black and non-Hispanic White respondents aged 19-50 years who gave birth in the previous 12 months were included (N=157,016). Postpartum insurance was categorized as Medicaid, private, or uninsured. Linear regression models compared expansion with nonexpansion states within Black and White respondents for each year before and after continuous coverage, with 2019 as the reference year. Covariate-adjusted regressions included respondents' age, employment status, and household income. Prepandemic uninsurance rates among Black women were 16.5% in nonexpansion states and 6.4% in expansion states, and among White women, they were 11.1% and 5.4%, respectively. Among Black women, uninsurance decreased after continuous coverage in nonexpansion states only. For example, in 2023, Black postpartum uninsurance decreased in nonexpansion states by 5.2 percentage points more (95% CI= -8.9, -1.5) than in expansion states; this was driven by a 3.9 percentage points larger gain in Medicaid in nonexpansion states than in expansion states (95% CI= -1.8, 9.6). Among White women, uninsurance decreases in 2021-2023 were also larger in nonexpansion states but were driven by gains in private insurance. As a result, Black-White disparities in postpartum uninsurance remained unchanged. Postpartum uninsurance decreased among Black women in nonexpansion states after continuous coverage, but racial inequities persisted.