States are in the midst of deciding whether and how to expand their Medicaid programs to nonelderly individuals with income below 133 percent of Federal Poverty Level (FPL), as permitted under the Affordable Care Act (ACA).  The group that perhaps stands to benefit the most from Medicaid expansion is women of childbearing age and their future children.

One of the ACA’s main goals was to address the upstream determinants of health, shifting the focus of the health care system “sick care” to “well care.”  However, the promise of preventive care will not be realized if women of childbearing age are denied access to health insurance coverage.  Medicaid expansion has the potential to drive meaningful improvements in maternal and child health by promoting health at every stage of life, including before and between pregnancies.

Today, Medicaid coverage is unavailable in most states to childless women who are not pregnant.

As a result, low-income women may have little or no source of regular health care before or between pregnancies, or after their childbearing is concluded.  These women often lack a medical home and go without both regular preventive care and acute care for illness or injury.   This lack of preconception and interconception care can have a significant impact on women’s health, and on the health of future pregnancies and children.  The ACA has the potential to transform this dynamic.

Medicaid Coverage Of Pregnant Women

At present, the vast majority of low-income women are ineligible for Medicaid coverage, as states are not required to extend coverage to women unless they are pregnant.  Under current federal rules, a woman is eligible for Medicaid coverage from the onset of pregnancy until 60 days postpartum, after which coverage ends.   Coverage may continue, however, for her newborn.  States that choose to cover non-pregnant low-income women have much more restrictive income eligibility levels for them than for women who are pregnant.

In 2010, over 8 million women of childbearing age with incomes below 138 percent FPL were uninsured. (Urban Institute tabulations of 2011 ASEC Supplement to the CPS. Unpublished estimates prepared for the Kaiser Family Foundation.)  It is well documented that lack of health coverage creates barriers to health care.  In 2007-2009, only 57 percent of uninsured women had a usual source of care, compared to over 90 percent of women with public or private insurance.  Uninsured women often delay or forgo regular preventive care and acute care for illness or injury.

The greatest opportunities to improve the health of a woman and her child during pregnancy, however, occur before a woman becomes pregnant.  The current structure of Medicaid eligibility significantly limits access to preventive care for low-income women, allowing potentially treatable conditions to go unaddressed until pregnancy is already established.

Medicaid Spending On Women’s And Children’s Health Care

In general, women and children account for a very modest proportion of health care spending, but the aggregate numbers mask important details. Children and their parents comprise 75 percent of Medicaid beneficiaries, but only 35 percent of costs. (See note 1 below.) However, while most care for adults and children without disabilities is inexpensive, hospital charges for birth and infant care represent a significant portion of Medicaid hospitalizations and associated costs. (See note 2 below.)

Medicaid currently covers approximately 41 percent all births across our nation, making it a major payer for maternity services. The proportion of births covered by Medicaid varies widely among states, ranging from 27 percent of births in New Hampshire to approximately 64 percent of births in Oklahoma. Research has shown that complex births are covered disproportionately by Medicaid; Medicaid paid for over half (53 percent) of all hospital stays for preterm and low birthweight infants, and about 45 percent of infant hospital stays due to birth defects in 2009. (See note 3 below.)

The significant role of Medicaid in covering maternity and newborn care has led many states and the Centers for Medicare and Medicaid Services (CMS) to focus increasing attention on pregnancy and birth outcomes.  Given that healthy women are more likely to have healthy pregnancies and deliver healthy babies, improving women’s preconception health has the potential to produce savings for Medicaid by improving birth outcomes.

The ACA’s Potential To Improve Health And Reduce Costs

The Affordable Care Act allows states to expand their Medicaid programs to cover childless adults up to 133 percent FPL.  Overall, 30.3 percent of individuals newly eligible for Medicaid under the ACA would be women of childbearing age, representing 4.6 million women, 3.4 million of whom have incomes below 100 percent FPL. Through Medicaid expansion, states have an opportunity to improve access to care for women and their future children by removing financial barriers to preventive care that will improve women’s health, birth outcomes, and ultimately children’s health.

If a state chooses to expand its Medicaid program, low-income women of childbearing age would be able to obtain coverage before and between pregnancies, offering them access to services that could improve their overall and reproductive health.  These essential services include screening for high blood pressure and chronic conditions, tobacco cessation, weight-loss programs to reduce the risk of gestational diabetes, substance-abuse counseling, birth control to space pregnancies appropriately, and other preventive and therapeutic care.  Each of these would reduce demonstrated risk factors for poor pregnancy and birth outcomes.

While some states may consider establishing an Exchange  to be a viable substitute for covering their state’s uninsured population, this leaves a considerable proportion of low-income adults, including women of childbearing age, with no feasible way to obtain insurance.  Women with the lowest incomes (under 100 percent of FPL) are ineligible for the Advance Premium Tax Credit, which is available to others who purchase insurance through the health exchange.  Additionally, Medicaid has more comprehensive benefits and minimal cost-sharing requirements compared with private insurance plans.  Without Medicaid expansion, women with the greatest need for services will not have access to affordable coverage.

Improving the health of women of childbearing age could also have significant implications for state Medicaid spending.  For example, average first-year medical costs, including both inpatient and outpatient care, are about 10 times greater for preterm infants ($32,325) than for full-term infants ($3,325). Based on these estimates, for every 1,000 fewer babies born preterm, approximately $29 million in first-year medical costs would be saved.  Similarly, access to preconception and prenatal care are critical to reducing the risk of complicated births, which account for a large proportion of maternity and newborn care expenses.  Access to prenatal care has been associated with better birth outcomes and lower medical care costs.

As states consider whether to expand their Medicaid programs, the impact of coverage on women of childbearing age and their children should be a primary concern.  Medicaid expansion provides a critical opportunity to improve the health of women before and between pregnancies, thereby ensuring healthy pregnancies and newborns.  The March of Dimes looks forward to monitoring Medicaid expansion and measuring its impact on health outcomes for women throughout their childbearing years as well as their children’s health.

Note 1. Kaiser Commission on Medicaid and the Uninsured/Urban Institute estimates based on data from FY 2009 MSIS and CMS-64, 2012.  MSIS FY 2008 data were used for MA, PA, UT and WI but adjusted to 2009 CMS-64.

Note 2. Smith K, Natzke B, Christensen A. , “Rising Rates of Labor Induction and Cesarean Delivery:  Issues, Implications and Current Initiatives to Reduce Rates,”  MACPAC White Paper Draft prepared by Mathematica Policy Research.

Note 3. Medicaid financing of hospital births and hospital stays based on a principal diagnosis of prematurity and birth defects from the Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project, 2012. Estimates obtained using data from the Healthcare Cost and Utilization Project (HCUP).