Postpartum Medicaid extensions reduce uninsured status

Postpartum uninsurance declined among Black women in non-expansion states during the COVID-19 continuous Medicaid coverage policy, but racial gaps persisted, according to a new study at Columbia University Mailman School of Public Health. The research is the first to explicitly examine how the policy affected racial equity in postpartum insurance coverage while also considering states’ Medicaid expansion status under the Affordable Care Act (ACA). The study is published in the American Journal of Preventive Medicine.

Extending Medicaid coverage to 12 months postpartum is widely viewed as a key strategy to reduce maternal morbidity and mortality, particularly in states that did not expand Medicaid under the ACA. The continuous Medicaid coverage provision enacted at the onset of the COVID-19 pandemic created a natural experiment to evaluate how extended coverage policies affect postpartum insurance coverage.

“Postpartum is a crucial time for preventing postpartum morbidity and mortality. The postpartum period is one of intense physiologic and psychosocial adaptation and requires consistent monitoring of health to support women during this critical time,” said Teresa Janevic, Ph.D., associate professor of Epidemiology at Columbia Mailman School.

“Our goal was to examine changes in postpartum uninsurance, Medicaid coverage, and private insurance before and during the continuous coverage provision among Black and white women, and to understand how those changes differed in Medicaid expansion and non-expansion states.”

In 2022, Black women had twice the rate of pregnancy-related death within 42 days of delivery compared with non-Hispanic white women and were more than four times as likely to die from pregnancy-associated causes up to 12 months postpartum. Beyond mortality, research shows that the postpartum period also widens racial health disparities, with Black women experiencing higher rates of severe maternal morbidity, postpartum depression, hospital readmissions, and emergency department visits.

Under the American Rescue Plan Act (ARPA), 49 states have enacted laws extending Medicaid postpartum coverage to 12 months, making it one of the largest policy responses to the U.S. maternal health crisis.

Before the pandemic, postpartum uninsurance rates were significantly higher in states that had not expanded Medicaid. In 2019, 16.5% of Black women and 11% of white women in non-expansion states were uninsured postpartum, compared with 6.4% and 5.4%, respectively, in expansion states.

The study found that:

• Postpartum uninsurance among Black women fell significantly in non-expansion states after the continuous coverage policy. By 2023, postpartum uninsurance among Black women had declined five percentage points more in non-expansion states than in expansion states.
• These reductions were driven largely by increased Medicaid coverage. Among Black women in non-expansion states, postpartum Medicaid coverage rose from 38% in 2019 to 42% in 2023, peaking at 45% in 2021.
• Among white women, declines in postpartum uninsurance were also larger in non-expansion states, but were driven mainly by gains in private insurance (69%) rather than gains in Medicaid (20%).

Despite these improvements, Black–white disparities in postpartum uninsurance remained unchanged.

The researchers analyzed data from the American Community Survey (ACS) for 2016–2019 and 2021–2023 across all 50 states and the District of Columbia using data from IPUMS U.S., based on U.S. census microdata. The sample included 157,016 non-Hispanic Black and non-Hispanic white women who had given birth in the previous 12 months.

The study compared postpartum insurance coverage before the pandemic (2016–2019) with the period during the federal continuous coverage policy (2021–2023), adjusting for factors including age, employment status, and household income.

Janevic notes that the findings suggest policies extending Medicaid postpartum coverage can meaningfully reduce postpartum uninsurance, particularly in states that have not expanded Medicaid. However, the policy alone may not be sufficient to close racial gaps in maternal health.

“While racial inequities in insurance coverage persisted, our findings suggest that postpartum Medicaid extension plays an important role in improving access to postpartum care,” noted Janevic. “At the same time, it is unlikely to be sufficient on its own to address the U.S. Black maternal health crisis.”

The results also underscore the broader importance of Medicaid coverage for maternal health. Because Black women are more likely than white women to rely on Medicaid for pregnancy-related care, policies that reduce Medicaid access could disproportionately affect the maternal health outcomes of Black women.