Medicaid Expansion Offers Opportunities for Improving Maternal and Child Health

By Adam Searing, JD, MPH
Associate Professor of the Practice
Georgetown University McCourt School of Public Policy

By Donna Cohen Ross
Consultant on Medicaid and Early Childhood Policy

Substantial new research shows that the adoption of Medicaid expansion under the Affordable Care Act (ACA) has led to significant improvements in access to health coverage for women of childbearing age. Better access to coverage makes possible the continuum of care many women's health professional societies and community advocacy organizations recommend to increase women's use of preventive care, reduce avoidable adverse obstetric and gynecological health outcomes, increase early diagnosis of disease, and reduce maternal mortality. New studies also show that healthier mothers mean healthier babies – another benefit for states that expand Medicaid. 

While the research demonstrates that the advantages of expanding Medicaid are clear, it also demonstrates the consequences of not expanding Medicaid. States that do not expand Medicaid are missing a powerful opportunity to address stark racial disparities in maternal health. Medicaid expansion in the remaining states would help close the coverage gap among women of childbearing age and at least make a start in addressing persistent inequities, especially for women of color.

These findings and others are highlighted in a new paper, Medicaid Expansion Fills Gaps in Maternal Health Coverage Leading to Healthier Mothers and Babies, issued by the Center for Children and Families at Georgetown University's McCourt School of Public Policy. In the paper, we reviewed the growing body of evidence emphasizing that increasing coverage through Medicaid expansion can bridge gaps in women's health care and provide a crucial strategy for addressing this country's abysmal record on maternal mortality. We also give examples of how Medicaid expansion can support the inextricable link between the health of mothers and their babies. AMCHP members will find the issues raised in this paper central to their ongoing efforts to improve maternal and child health. Medicaid expansion is an important means for making progress on several Title V Maternal and Child Health Block Grant performance measures, particularly improving access to adequate insurance, well-woman visits, and risk-appropriate perinatal care. Medicaid coverage also increases access to services aimed at reducing smoking, promoting breastfeeding, and increasing safe sleep practices for infants.

As the report illustrates, Medicaid expansion offers opportunities for achieving vital maternal and child health goals:

Advancing health equity. The United States has one of the highest rates of maternal mortality in the industrialized world. Underlying our poor record is an unacceptable racial disparity: Black women and American Indian/Alaska Native women are approximately three times as likely as white women to die of pregnancy-related causes. Maternal mortality reviews show that the majority of these deaths are preventable and offer ways to change course. 

Our review of multiple studies and state health coverage data shows that while better quality care, better data to inform health care decisions, better health care facilities, and care that values women well before and well after childbirth are all necessary, covering all women of childbearing age with quality, affordable health insurance is central to moving forward. In the South, which comprises most of the 14 remaining non-expansion states, rates of uninsurance are higher and African Americans are disproportionately affected.

Increasing insurance rates – and access to better care. Medicaid expansion and other elements of the ACA have led to a significant decrease in the uninsured rate for women of childbearing age. Our analysis shows that the uninsured rate for women in non-expansion states is nearly twice as high as in states that have expanded Medicaid. And coverage before, during, and after childbirth opens the door to better care overall. For example, women in expansion states get earlier prenatal care and more timely treatment for chronic health conditions like hypertension and depression. In addition, whereas many low-income women in non-expansion states who are eligible for Medicaid by virtue of their pregnancy risk losing Medicaid coverage 60 days postpartum, low-income women in Medicaid expansion states maintain their coverage regardless of pregnancy status.

Improved birth outcomes. Multiple recent studies show that states that expand Medicaid experience significant benefits for mothers and infants. Women in expansion states had earlier initiation of prenatal care, better care before becoming pregnant, and lower rates of maternal mortality. Medicaid expansion states have also seen significant reductions in infant mortality; the decline in infant mortality between 2010 and 2016 in Medicaid expansion states was more than 50 percent greater than in non-expansion states. Further, the decline in infant mortality rates linked to Medicaid expansion was greatest among African American infants, which drove the overall decline in infant mortality.

Two-generation advantages. Medicaid-covered services for adults can benefit children as well. For example, Medicaid provides women with screening for maternal depression, a widespread condition that takes a significant toll on the mother herself, and as a result can compromise a child's early brain development, with implications for the child's cognitive, social, and emotional health. State Medicaid programs must make depression screening without cost-sharing available to women enrolled under a state's Medicaid expansion and refer women at risk of perinatal depression to counseling. In Medicaid expansion states, more mothers have access to more intensive therapy or medication, if needed.

Medicaid also covers tobacco use cessation services, with the ACA requiring such benefits without cost-sharing for pregnant women and for populations made newly eligible under Medicaid expansions. Smoking cessation can not only reduce a woman's risk of cardiovascular and respiratory disease, cancer, and other chronic conditions; it also decreases the chances of pregnancy-related complications, including preterm birth, low birth weight, and sudden infant death syndrome. When adults quit smoking, they also reduce the likelihood that their children will suffer from exposure to second-hand smoke, which can trigger more frequent and severe asthma attacks and is associated with ear infections and even tooth decay.

Conclusion. Recent studies show that Medicaid expansion has reduced the uninsured rate of women of childbearing age and has improved health outcomes. Medicaid expansion has also played a role in reducing rates of maternal death, decreasing infant mortality rates, and improving the potential for optimal birth outcomes that can increase the prospects for a healthy future. It is clear that expanding Medicaid is an effective tool to help babies get the best start in life and address significant racial disparities in maternal and infant health.