Project Summary/Abstract
Timely, high-quality prenatal care is associated with improved child and maternal health outcomes, and
comprehensive health insurance coverage during pregnancy facilitates access to prenatal care. The Affordable
Care Act (ACA) included prenatal and maternity care as one of the ten essential health benefits that must be
covered in Marketplace plans (i.e., commercial insurance plans for individuals). ACA Marketplaces are an
important source of health insurance for pregnant people who are not eligible for Medicaid or employer-
sponsored insurance. However, current Marketplace enrollment policies make it challenging to enroll in
a Marketplace plan early in pregnancy, which may have adverse consequences for access to prenatal
care and child and maternal health outcomes.
All Marketplace plans have an annual open enrollment period (OEP) from approximately November to
January. An individual can enroll in a Marketplace plan outside of the annual OEP only through a special
enrollment period (SEP), which is a limited time window after a qualifying life event (e.g., loss of insurance
coverage, or household change [including childbirth]). The ACA did not include pregnancy as a qualifying
event for SEP Marketplace coverage. Therefore, people who become pregnant outside of the OEP must
delay Marketplace enrollment until they have an eligible SEP-qualifying event, the next annual OEP, or give
birth. In recent years, six U.S. states have enacted policy to include pregnancy as a Marketplace SEP-
qualifying event, meaning that people in these states can enroll in a Marketplace plan when they become
pregnant. We hypothesize that this policy facilitates Marketplace enrollment earlier in pregnancy, increases the
percent of pregnant people on the Marketplace who receive timely, high-quality prenatal care, and improves
maternal and infant health outcomes for Marketplace enrollees.
Our study will exploit a natural experiment created by state-level variation in Marketplace SEP eligibility
rules to estimate the impact of a policy to include pregnancy as a SEP-qualifying event. Specifically, we will
first (Aim 1) describe the role of the Marketplace in providing health insurance coverage and access to
prenatal care for pregnant people (Aim 1). We will then use a robust quasi-experimental design to evaluate the
impact of including pregnancy as an SEP-qualifying event on (Aim 2) timely prenatal care and (Aim 3) infant
and maternal health outcomes for pregnant people who enroll in Marketplace. We will use all-payer claims data
from New York (intervention state) and Massachusetts (control state) from 2014-2019, which provide many
advantages over data used in prior research of pregnant people on the Marketplace. The findings from our
study will provide critical and timely information for state-level and federal-level policy-makers to ensure that
Marketplace coverage is (i) accessible for pregnant people without other insurance coverage options, and (ii)
effective in improving prenatal care and, ultimately, child and maternal health outcomes.
