Continuous Medicaid Eligibility During the COVID-19 Pandemic and Postpartum Coverage, Health Care, and Outcomes

Abstract

Importance: Pursuant to the Families First Coronavirus Response Act (FFCRA), continuous Medicaid eligibility during the COVID-19 public health emergency (PHE) created a de facto national extension of pregnancy Medicaid eligibility beyond 60 days postpartum.

Objective: To evaluate the association of continuous Medicaid eligibility with postpartum health insurance, health care use, breastfeeding, and depressive symptoms.

Design, setting, and participants: This cohort study using a generalized difference-in-differences design included 21 states with continuous prepolicy (2017-2019) and postpolicy (2020-2021) participation in the Pregnancy Risk Assessment Monitoring System (PRAMS).

Exposures: State-level change in Medicaid income eligibility after 60 days postpartum associated with the FFCRA measured as a percent of the federal poverty level (FPL; ie, the difference in 2020 income eligibility thresholds for pregnant people and low-income adults/parents).

Main outcomes and measures: Health insurance, postpartum visit attendance, contraceptive use (any effective method; long-acting reversible contraceptives), any breastfeeding and depressive symptoms at the time of the PRAMS survey (mean [SD], 4 [1.3] months postpartum).

Results: The sample included 47 716 PRAMS respondents (64.4% aged <30 years; 18.9% Hispanic, 26.2% non-Hispanic Black, 36.3% non-Hispanic White, and 18.6% other race or ethnicity) with a Medicaid-paid birth. Based on adjusted estimates, a 100% FPL increase in postpartum Medicaid eligibility was associated with a 5.1 percentage point (pp) increase in reported postpartum Medicaid enrollment, no change in commercial coverage, and a 6.6 pp decline in uninsurance. This represents a 40% reduction in postpartum uninsurance after a Medicaid-paid birth compared with the prepolicy baseline of 16.7%. In subgroup analyses by race and ethnicity, uninsurance reductions were observed only among White and Black non-Hispanic individuals; Hispanic individuals had no change. No policy-associated changes were observed in other outcomes.

Conclusions and relevance: In this cohort study, continuous Medicaid eligibility during the COVID-19 PHE was associated with significantly reduced postpartum uninsurance for people with Medicaid-paid births, but was not associated with postpartum visit attendance, contraception use, breastfeeding, or depressive symptoms at approximately 4 months postpartum. These findings, though limited to the context of the COVID-19 PHE, may offer preliminary insight regarding the potential impact of post-pandemic postpartum Medicaid eligibility extensions. Collection of longer-term and more comprehensive follow-up data on postpartum health care and health will be critical to evaluating the effect of ongoing postpartum policy interventions.

Figure 1.. Variation in the Families First Coronavirus Response Act (FFCRA)-Associated Postpartum Medicaid Eligibility Change Among 21 Sample States

The FFCRA-associated postpartum Medicaid eligibility change is the difference in the income eligibility level for pregnancy Medicaid and for low-income adults/parents in each state in 2020. This change represents the effective increase in the Medicaid income eligibility level after 60 days postpartum that resulted from the maintenance of effort provision of the FFCRA. States with a larger eligibility increase had more people who became newly eligible for continued Medicaid after pregnancy (and thus did not lose Medicaid eligibility postpartum) during the COVID-19 public health emergency. eTable 1 in Supplement 1 provides additional details on state-level income eligibility criteria. FPL indicates federal poverty level.

Figure 2.. Percent Change in the Outcomes Associated With a 100% Federal Poverty Level (FPL) Increase in Postpartum Medicaid Eligibility

Percent change is calculated as the adjusted difference-in-difference estimate for a 100% FPL change in postpartum Medicaid eligibility relative to the prepolicy baseline (2017-2019). Postpartum outcomes are measured at the time of the Pregnancy Risk Assessment Monitoring System survey (mean, 4 months after a live birth). Depressive symptoms are defined as a positive screen (score ≥3) on the PRAMS-modified Patient Health Questionnaire-2. LARC indicates long-acting reversible contraception including intrauterine devices and birth control implants. ^aP = .004.