Medicaid Expansion is a hot topic in policy circles again these days. States that are looking to adopt Expansion for the first time can now do so with the benefit of hindsight and meaningful data. As someone who has worked on Medicaid policy for nearly a decade, I am focused on new insights and evidence that speak to the effectiveness of these coverage expansion policies.
With nearly five years of Expansion experience under the country’s belt, researchers are now able to draw from outcomes and survey data to conduct analyses on whether the expanded coverage is really delivering on the promise of improved health.
Two recently released studies indicate that may be the case, particularly regarding obstinate and worsening national health challenges like maternal and infant mortality. This spring, both the Journal of the American Medical Association (JAMA) and the Georgetown University Health Policy Institute released separate studies pointing to the coverage gains of Medicaid Expansion in improving maternal health outcomes and reducing racial disparities in maternal and infant mortality.
The study released in JAMA in late April focuses on child health outcomes and compared nearly 16 million births across 35 states, 18 of which expanded Medicaid and 17 of which did not, to compare outcomes relative to Medicaid coverage status. Infant mortality is a key indicator of the health and effectiveness of the health care system. With 23,161 infant deaths (5.9 deaths per 1,000 live births) in 2016, the United States’ infant mortality rate remains consistently higher than that of other developed countries.
Maternal Mortality Prevalence in the United States, 2018 | Source: America’s Health Rankings; CDC WONDER Online Database, Mortality files | Link: https://www.americashealthrankings.org/explore/health-of-women-and-children/measure/maternal_mortality
Nationally, significant disparities persist in infant mortality, predominantly regarding race. The rate of infant mortality for babies born to black women is more than two times the rate for babies born to white women. While the JAMA study did not find any significant improvement in key outcome indicators like preterm birth and low birth weight in Expansion vs. Non-Expansion states, it did find that Expansion states experienced significant improvements in the racial disparities across these indicators.
Maternal Mortality Rates in the United States by Race/Ethnicity | Source: Source: America’s Health Rankings; CDC WONDER Online Database, Mortality files, 2011-2015 | Link: https://www.americashealthrankings.org/explore/health-of-women-and-children/measure/maternal_mortality
While Expansion coverage is not directly leading to overall improvement in outcomes, the fact that the racial disparities are decreasing in states with Expansion indicates that getting Medicaid coverage to groups that may be disproportionately uninsured, such as black women, helps them achieve outcomes on par with their counterparts who likely have greater access to coverage.
The Georgetown study, released in May, focused its research on the impacts of Expansion on maternal health outcomes. Despite a global downturn in maternal mortality, rates of death due to pregnancy or childbirth in the United States have grown since 2000, to 20.7 deaths per live births, leading the U.S. to have the highest rate of maternal mortality among industrialized nations.
Agnostic of whether they adopted Expansion, all states must provide expanded Medicaid eligibility for pregnant women. However, that coverage is often limited to delivery and does not extend to the months before giving birth. Receiving appropriate screenings, care and treatment during those months – including for depression and tobacco/drug use – is critical in addressing maternal mortality and morbidity.
The Georgetown study found that increased prenatal care is associated with reducing adverse health outcomes before, during, and after pregnancies. It also reduces maternal mortality rates and improves racial disparities in maternal outcomes. Of particular note, the study found that states that adopted Medicaid Expansion experienced significant increases in pregnant women receiving all recommended health screens, along with a 14 percent increase in receipt of prenatal vitamins for first-time mothers.
While the body of research on the impact of Expansion grows, it is crucial to continue to monitor the effects of coverage on access to and provision of basic care to improve the health of women and children. I will be closely watching how these findings play out in states considering the Medicaid Expansion option, particularly those with poor maternal and child health outcomes.