Established Evidence Results

Intervention Components (click on component to see a list of all articles that use that intervention): Health Insurance Coverage,

Intervention Description: Continuous Medicaid eligibility Vs. pregnancy-only Medicaid after delivery

Intervention Results: After adjusting for maternal characteristics, women with continuous Medicaid eligibility had a postpartum visit rate that was 6 percentage points higher than the rate for women with pregnancy-only Medicaid

Conclusion: Women with pregnancy-only Medicaid were less likely to have received routine postpartum care than women with continuous Medicaid. Medicaid coverage beyond the current guaranteed 60 days postpartum could help provide more women access to postpartum care.

Study Design: Observational study that used linked Medicaid claims, Medicaid eligibility, and infant birth certificates

Setting: Birth settings where Medicaid is accepted

Population of Focus: Women who reside in Wisconsin and delivered at least one live birth during 2011–2015 that was paid for by Medicaid

Sample Size: 105718

Age Range: <20--≥35

Intervention Components (click on component to see a list of all articles that use that intervention): Medicaid Reform,

Intervention Description: Medicaid expansion after implementation of the Affordable Care Act (ACA)

Intervention Results: "Income eligible" women had approximately a 5.0 percentage point increased likelihood of both a postpartum visit and use of long-acting reversible contraceptives. Women who entered Ohio Medicaid in the "pregnancy eligible" category had a 7.7 percentage point increase in the probability of remaining continuously enrolled 6 months postpartum relative to those entering as income eligible. However, there was no significant change in postpartum visit attendance in the latter group."

Conclusion: Ohio's ACA Medicaid expansion was associated with a significant increase in the probability of women's continuous enrollment in Medicaid and use of long-acting reversible contraceptives through 6 months postpartum.

Study Design: Retrospective cohort study

Setting: Birth settings where Medicaid is accepted

Population of Focus: Pregnant and postpartum women in Ohio who had both a Medicaid birth and 6-month postpartum period between January 2011 and June 2013 or between November 2014 and December 2015, when the ACA Medicaid expansion was implemented in that state.

Sample Size: 170787

Age Range: ≥19

Intervention Components (click on component to see a list of all articles that use that intervention): Medicaid Reform, Expanded Insurance Coverage,

Intervention Description: Maternal coverage and care use were compared among women with family incomes 100% to 138% of the federal poverty level (FPL) residing in 10 Medicaid expansion sites (exposure group) who gained Medicaid eligibility under the Affordable Care Act and in 5 nonexpansion sites (comparison group) who gained marketplace eligibility before (2011-2013) and after (2015-2018) insurance expansion implementation.

Intervention Results: Medicaid eligibility relative to marketplace eligibility was associated with significantly increased Medicaid coverage (20.3 percentage points), decreased private insurance coverage (−10.8 percentage points), and decreased uninsurance (−8.7 percentage points) in the preconception period. It was also associated with increased postpartum Medicaid (17.4 percentage points) and increased adequate prenatal care (4.4 percentage points) but not with significant changes in early prenatal care, postpartum checkups, or postpartum contraception.

Conclusion: In this cohort study, eligibility for Medicaid was associated with increased Medicaid, lower preconception uninsurance, and increased adequate prenatal care use. The lower rates of preconception uninsurance among Medicaid-eligible women suggest that women with low incomes were facing barriers to marketplace enrollment, underscoring the potential importance of reducing financial barriers for the population with low incomes.

Study Design: Cohort study

Setting: 10 Medicaid expansions states; 5 non-expansion states

Population of Focus: Women with low incomes

Sample Size: 11432

Age Range: >18

Intervention Components (click on component to see a list of all articles that use that intervention): Medicaid Reform, Expanded Insurance Coverage,

Intervention Description: The expansion of Medicaid under the Affordable Care Act (ACA) in Colorado in 2013-2015, compared with the state of Utah, which did not expand Medicaid.

Intervention Results: Before Medicaid expansion, the mean number of postpartum outpatient visits in Medicaid was higher in Colorado than in Utah. After expansion, the number of visits increased in Colorado and decreased in Utah, resulting in a 17.3 percent increase in outpatient utilization relative to the baseline rate in Colorado, or 0.52 additional Medicaid-financed visits in the six months after delivery, compared to women in Utah. Utilization increases were significantly greater among women who experienced severe maternal morbidity at the time of their deliveries. Among these women, Colorado’s expansion was associated with 1.3 Medicaid-financed postpartum outpatient visits compared to 0.5 visits among women without severe maternal morbidity, a relative increase of 46.3 percent from Colorado’s baseline mean

Conclusion: After Medicaid expansion in Colorado but not Utah, new mothers in Utah experienced higher rates of Medicaid coverage loss and accessed fewer Medicaid-financed outpatient visits during the six months postpartum, relative to their counterparts in Colorado. The effects of Medicaid expansion on postpartum Medicaid enrollment and outpatient utilization were largest among women who experienced significant maternal morbidity at delivery. These findings provide evidence that expansion may promote the stability of postpartum coverage and increase the use of postpartum outpatient care in the Medicaid program.

Study Design: Two-state claims-based analysis of the effect of Medicaid expansion on postpartum Medicaid coverage and use of postpartum outpatient care

Setting: Birth settings where Medicaid is accepted

Population of Focus: Women who had live births paid for by Medicaid during the period January 2013-June 2015 in Colorado and Utah.

Sample Size: 25,805 deliveries from 24,528 women in Utah and 44,647 deliveries from 42,144 women in Colorado.

Age Range: ≥19

Intervention Components (click on component to see a list of all articles that use that intervention): Medicaid Reform, Expanded Insurance Coverage,

Intervention Description: Passage of the Reproductive Health Equity Act, which included coverage for 60 days of postpartum care, including contraception, for the Emergency Medicaid population. In Oregon, this Act went into effect in April 2018.

Intervention Results: Before the policy change, 8.8% of Emergency Medicaid enrollees (1050 women) attended a postpartum visit. After the policy, 55.6% of Emergency Medicaid enrollees (1933 women) attended a postpartum visit. In our adjusted DID model, assuming parallel trends, the policy was associated with an increase in postpartum visit attendance of 40.6 percentage points (95% CI, 34.1-47.1 percentage points; P < .001). Assuming differential trends, the policy was associated with an increase in postpartum visit attendance of 47.9 percentage points (95% CI, 41.3-54.6 percentage points; P < .001)

Conclusion: These findings suggest that expanding Emergency Medicaid benefits to include postpartum care is associated with significant improvements in receipt of postpartum care and contraceptive use.

Study Design: Cohort study and difference-in-difference analysis

Setting: Birth settings where Medicaid is accepted

Population of Focus: Immigrant women eligible for emergency Medicaid in Oregon

Sample Size: 27,667 live births among 23,971 women

Age Range: <20--≥35

Intervention Components (click on component to see a list of all articles that use that intervention): Medicaid Reform, Expanded Insurance Coverage,

Intervention Description: Medicaid extended beyond 60 days postpartum for those with an income below 138% of the FPL

Intervention Results: Medicaid expansion in Arkansas was associated with a 27.8 (95% CI, 26.1-29.5) percentage point increase in continuous insurance coverage and an increase in outpatient visits of 0.9 (95% CI, 0.7-1.1) during the first 6 months postpartum, representing relative increases of 54.9% and 75.0%, respectively. Racial disparities in postpartum coverage decreased from 6.3 (95% CI, 3.9-8.7) percentage points before expansion to −2.0 (95% CI, −2.8 to −1.2) percentage points after expansion. However, disparities in outpatient care between Black and White individuals persisted after Medicaid expansion (preexpansion difference, 0.4 [95% CI, 0.2-0.6] visits; postexpansion difference, 0.5 [95% CI, 0.4-0.6] visits).

Conclusion: In this cohort study with a difference-in-differences analysis of 60 990 childbirths, Medicaid expansion was associated with higher rates of postpartum coverage and outpatient visits and lower racial and ethnic disparities in postpartum coverage. However, disparities in outpatient visits between Black and White individuals were unchanged. Additional policy approaches are needed to reduce racial and ethnic disparities in postpartum care.

Study Design: Quasi-experimental cohort study with a difference-in-differences analysis

Setting: Birth settings where Medicaid is accepted

Population of Focus: Low-income postpartum women eligible for expanded Medicaid

Sample Size: 60,990 childbirths

Age Range: 19-50

Intervention Components (click on component to see a list of all articles that use that intervention): Medicaid Reform, Expanded Insurance Coverage,

Intervention Description: Expansion of Medicaid under the Families First Coronavirus Response Act (FFCRA) of 2020 which required that state Medicaid programs provide continuous coverage to enrollees through the end of the COVID-19 public health emergency (PHE)

Intervention Results: Within 90 days of delivery, postpartum services utilization was comparable Post- Families First Coronavirus Response Act (FFCRA) vs. Pre-FFCRA. After 90 days postpartum, however, Post-FFCRA utilization was 2-fold higher than Pre-FFCRA utilization (6.7 vs. 3.2%, respectively. The same patterns were observed when examining all outpatient services utilization. Although overall outpatient services utilization decreased after 90-days postpartum, Post-FFCRA utilization was 2–5-fold higher than Pre-FFCRA utilization through the end of the first-year postpartum, with 17.7% of Post-FFCRA women receiving outpatient care between 91- and 182-days and 17.9% between 183- and 365-days postpartum, vs. 3.4 and 8.8% for Pre-FFCRA women, respectively.

Conclusion: Our analysis demonstrates that the FFCRA's continuous coverage requirement is associated with a sustained increase in preventive services utilization throughout the first-year postpartum. Other benefits include increased utilization of contraceptive services, decreased incidence of short interval pregnancies, and increased utilization of MBH/SUD services.

Study Design: Retrospective cohort study and secondary analysis

Setting: Parkland Community Health Plan (a Texas Medicaid Health Maintenance Organization)

Population of Focus: Singleton postpartum women enrolled in Medicaid

Sample Size: 3,465 Pre-FFCRA and 5,411 Post-FFCRA deliveries

Age Range: 14-48