Impact of 12-month Postpartum Insurance Extensions on Maternal and Newborn Health - ABSTRACT The United States is experiencing a maternal health crisis. Maternal mortality and severe maternal morbidity (SMM) affect around 700 and 60,000 women, respectively, every year, and the numbers are increasing. Hidden in these averages are disparities with Black and American Indian women, women on Medicaid insurance, and women residing in rural areas bearing the disproportionate burden of maternal mortality and SMM. Over half of these maternal deaths occur in the postpartum period with maternal mortality and SMM remaining well elevated beyond 42 days postpartum. The postpartum period is a critical period for addressing maternal mortality and SMM and this has been endorsed by professional organizations emphasizing the importance of postpartum care being an ongoing process rather than a single encounter. However, use of postpartum care is deficient even for high-risk patients. As a result, maternal outcomes are suboptimal and result in excess harm. One reason for this inadequate use of recommended care is typical coverage limits on Medicaid insurance for pregnancy. Traditionally, Medicaid provides pregnancy related coverage for eligible recipients through 60 days postpartum. After that, many beneficiaries lose coverage restricting access to postpartum care. During the COVID-19 pandemic, the Families First Coronavirus Response Act halted Medicaid disenrollments since March 2020 resulting in continuous coverage for pregnant women beyond 60 days postpartum, but this expired on March 31, 2023. Meanwhile, the American Rescue Plan Act of March 2021 provided states with federal funding to extend postpartum coverage up to one year. This extended postpartum coverage created a unique opportunity to examine the impact of postpartum insurance coverage continuity. Thus, we propose to make use of a natural experiment comparing women on Medicaid (treatment group) to women on commercial (control group) insurance during their delivery hospitalization within 15 states before and after state policy adoption of postpartum Medicaid coverage extensions. We will build upon unique population-based datasets that we have amassed and combine over 25 years (2008-2026) of vital statistics birth and death records linked with maternal and newborn hospital discharge data across 15 U.S. states. Using a difference-in-differences methodology, we will examine the effect of 1-year postpartum Medicaid coverage extensions on: 1) short interpregnancy interval and preterm birth and low birth weight outcomes, 2) infant hospitalizations and ED use, 3) postpartum maternal hospitalizations, ED use, and SMM, and 4) disparities in the above outcomes by race/ethnicity, rural/urban residence, state Medicaid expansion versus non-expansion status, and state income eligibility limits for pregnant women. At the completion of this project, we will have rigorous evidence on whether continuous postpartum insurance coverage is improving maternal and newborn outcomes and mitigating disparities.
