Postpartum Medicaid expansion improved coverage but showed limited care changes

The federal policy requiring states to keep Medicaid beneficiaries enrolled during the COVID-19 pandemic extended postpartum Medicaid coverage nationwide and sharply increased the number of individuals remaining insured after childbirth, according to a Rutgers Health researcher.

An analysis, published in The Milbank Quarterly, of Medicaid claims in 15 states finds that this coverage expansion produced modest changes in health care use, with notable increases in emergency department visits and mental and behavioral health diagnoses.

Medicaid claims data provide us with important insights into service utilization and maternal health outcomes. Yet because we typically rely on claims data, which show us what care was billed, we do not necessarily know whether individuals understood that they remained covered or what barriers they may have faced in seeking care."

Erica Eliason, assistant professor at the Rutgers Center for State Health Policy and the Rutgers School of Public Health and lead author of the analysis

The Families First Coronavirus Response Act's continuous coverage requirement offered enhanced federal funding to states in exchange for pausing disenrollment and produced greater insurance continuity for postpartum individuals.

This study, which involved nearly 489,000 postpartum individuals, examined how extended eligibility under the act affected Medicaid enrollment, continuity of coverage and use of Medicaid-paid health care from three to 12 months after childbirth – a period not previously covered for those insured through pregnancy Medicaid.

It compared postpartum Medicaid outcomes during the pandemic-era continuous coverage period with outcomes from a year earlier.

The share of individuals maintaining Medicaid coverage through 12 months postpartum increased to 77% from 37% before the Families First Coronavirus Response Act during its implementation.

In the three- to 12-month postpartum period, when pregnancy Medicaid would usually have ended, extended eligibility was associated with more Medicaid-paid emergency department visits and a higher proportion of individuals receiving services with mental or behavioral health diagnoses.

However, the analysis did not identify increases in outpatient visits or pregnancy-related diagnoses during the extended coverage period. For example, although extended eligibility increased emergency department use by about 107 visits per 1,000 beneficiaries, outpatient visits did not show statistically significant changes.

Eliason said it is difficult to determine whether beneficiaries sought care outside Medicaid, whether awareness of continued coverage influenced care-seeking or how pandemic-related service disruptions shaped overall care utilization.

The authors of the analysis emphasized the importance of taking a patient-centered approach to extending postpartum coverage. They said the 49 states that have adopted 12-month postpartum coverage should pair the extension with communication and outreach strategies to ensure individuals are aware of and able to use their postpartum Medicaid coverage.

"I would advise policymakers that continuous postpartum coverage is an important tool for states to monitor and improve health outcomes for postpartum people and their babies," Eliason said. "But without strong communication and support, expanded eligibility may not fully translate into improved access or outcomes."

The study's authors, based at Rutgers and the University of Maryland, called for future research examining postpartum coverage and health outcomes for additional populations, over longer periods of time and under stable public health conditions.