Stacey McMorrow, Lisa Dubay, Genevieve M. Kenney, Emily M. Johnston,
and Clara Alvarez Caraveo
May 2020
Alarming increases in US maternal mortality have generated national attention, a search for policy
solutions to promote maternal health, and an increased recognition of how important the postpartum
period is for mothers’ and infants’ health and well-being. Without access to consistent, comprehensive
health insurance coverage, many new mothers can face extreme challenges obtaining the care they
need to support their and their infants’ health. This analysis uses 2015–18 data from the National
Health Interview Survey (NHIS) to document access and affordability challenges facing uninsured new
mothers and 2015–17 data from the Pregnancy Risk Assessment and Monitoring System (PRAMS), a
state-specific surveillance system of pregnancies resulting in a live birth, to describe the health status of
women who lost Medicaid coverage following their pregnancies. Together, our analysis provides new
evidence on the access and affordability barriers that could be reduced and the health problems that
could be treated if these uninsured new mothers were to gain coverage through a postpartum Medicaid
extension or broader Medicaid expansion.
Key Findings
Approximately 11.5 percent of new mothers nationwide were uninsured from 2015 to 2018;
just over half of those uninsured new mothers were Hispanic, and close to two-thirds lived in
the South.
About 1 in 5 uninsured new moms reported at least one unmet need for medical care because
of cost in the past year, and over half were very worried about paying their medical bills.
HEALTH POLICY CENTER
Uninsured New Mothers’
Health and Health Care
Challenges Highlight the Benefits of Increasing
Postpartum Medicaid Coverage
2
THE BENEFITS OF INCREASING POSTPARTUM MEDICAID COVERAGE
Roughly half of all uninsured new mothers reported that losing Medicaid or other coverage
after pregnancy was the reason they were uninsured, suggesting that they would likely benefit
from an extension of postpartum Medicaid coverage.
Almost one-third of women who lost Medicaid coverage and became uninsured in the
postpartum period were obese before their pregnancy, and 18 percent reported either
gestational diabetes or pregnancy-related hypertension, all conditions that require ongoing
monitoring and care after giving birth.
About one-third of new moms who lost Medicaid were recovering from a cesarean section, and
just over one-quarter reported being depressed sometimes, often, or always in the months after
giving birth.
Altogether, our findings indicate that many uninsured new mothers report trouble affording care
and have both physical and mental health needs that would benefit from the more consistent access to
coverage and care that expanding Medicaid would provide. These findings are particularly relevant
given the COVID-19 pandemic and ensuing economic crisis, which will put even more women at risk of
uninsurance and in need of affordable coverage options before, during, and after pregnancy.
Background
Alarming increases in maternal mortality in the United States (with large, persistent disparities by race
and ethnicity) have generated national attention and a search for policy solutions to promote maternal
health.
1
Although the majority of maternal deaths occur during pregnancy or within one week of
delivery, about 33 percent occur more than seven days after delivery, and 12 percent occur more than
six weeks after birth (Petersen et al. 2019). Severe maternal morbidity has also been increasing,
2
and
these serious delivery complications can lead to more difficult recoveries and require additional follow-
up care among new mothers. Moreover, recognition is growing of the importance of the postpartum
period for mothers’ and infants’ well-being (ACOG 2018). During this period, sometimes referred to as
the “fourth trimester,” women need a comprehensive assessment of their physical recovery from birth,
of their reproductive and sexual health needs, and of their emotional well-being. They also need plans
for ongoing chronic disease management and health maintenance beyond the immediate postpartum
period. Without access to consistent, comprehensive health insurance coverage following pregnancy,
many new mothers can face extreme challenges obtaining the care they need to support their and their
infants’ health.
Insurance coverage transitions during the perinatal period have been a long-standing concern for
many mothers, particularly for the approximately 50 percent of women who have Medicaid coverage
for their pregnancy and delivery (D’Angelo et al. 2015). From 2005 to 2013, approximately 55 percent
of women who had Medicaid or CHIP coverage at delivery were uninsured at some point in the
following six months (Daw et al. 2017). These patterns are largely because of Medicaid policy that
extends pregnancy-related eligibility to women with incomes up to 200 percent of the federal poverty
level in most states but ends that coverage 60 days after they have given birth. At that point, if women
THE BENEFITS OF INCREASING POSTPARTUM MEDICAID COVERAGE
3
are not eligible for Medicaid under their state’s parental eligibility rules (which have much lower income
eligibility thresholds than pregnancy-related Medicaid in most states) many women become uninsured.
Moreover, immigrant women face additional eligibility rules that can be more restrictive for parents
than for pregnant women, leading to coverage losses. To reduce these coverage disruptions and
associated barriers to accessing needed care after giving birth, several federal and state-specific
proposals aimed at addressing maternal mortality and morbidity have included a provision that would
extend pregnancy-related Medicaid coverage for a year after giving birth.
3
Recent evidence suggests that new mothers have already benefited from broader efforts to expand
coverage under the Affordable Care Act (ACA). The uninsurance rate among all new mothers fell from
19.2 to 11.3 percent between 2013 and 2016,
4
with large coverage gains across all racial and ethnic
groups and reductions in disparities for both black and Hispanic adults (Johnston et al. 2019). Among
new mothers with incomes below the federal poverty level, the ACA Medicaid expansion reduced
uninsurance 28 percent (Johnston et al. 2020). In 2017, however, approximately 451,000 new mothers
remained uninsured, and about half were US citizens with incomes below 200 percent of the federal
poverty level who would be most likely to benefit from an extension of postpartum Medicaid eligibility.
5
Although the maternal mortality crisis has been a catalyst for reforms focused on postpartum
insurance coverage, just one published study has examined the impact of insurance coverage on
maternal mortality. Eliason (2020) finds that the ACA Medicaid expansion was associated with
approximately seven fewer maternal deaths per 100,000 live births, though the exact mechanism
behind the effect is unclear, and expanded preconception coverage is likely an important factor. Based
on decades of research, however, the benefits of expanding coverage extend well beyond effects on
mortality alone. Many studies have demonstrated the impacts of the ACA and other insurance
expansions on access to care and health status for adults, pregnant women, and parents (Antonisse et al.
2018; Finkelstein et al. 2012; Howell 2001; Lee et al. 2020; Margerison et al. 2020; McMorrow et al.
2017;McWilliams 2009; Wherry 2018), so like these other populations, new mothers would likely
benefit from additional coverage gains. In fact, a study of new mothers in Colorado found that the ACA
Medicaid expansion increased their utilization of postpartum care (Gordon et al. 2020). Moreover,
coverage gains for new mothers could also produce both short- and long-term benefits for the health
and well-being of their infants and other children (Hudson and Moriya 2017; Wherry, Kenney, and
Sommers 2016; Wright Burak 2017).
In this brief, we use data from the NHIS to document some of the access and affordability
challenges facing uninsured new mothers following enactment of the major coverage provisions of the
ACA, and we further describe the health status of women who lost Medicaid coverage following their
deliveries using data from the PRAMS. Together, our analysis provides new evidence on the access and
affordability barriers that could be reduced and the health problems that could be treated if these
uninsured new mothers were to gain coverage through an extension of postpartum Medicaid eligibility.
4
THE BENEFITS OF INCREASING POSTPARTUM MEDICAID COVERAGE
Data and Methods
National Health Interview Survey, 2015–18.
We use data from the NHIS, which we obtain from the Integrated Public Use Microdata Series (IPUMS)
at the University of Minnesota (Ruggles et al. 2020). We define new mothers as women ages 19 to 44
with a child under age 1 whose NHIS record points to the woman as his or her biological or adoptive
mother. We focus on new mothers who did not have any insurance coverage at the time of the survey.
We pool data from 2015 to 2018 because the sample of uninsured new mothers in the NHIS is quite
small (i.e., approximately 450 overall and 200 for most access and affordability measures when pooled
across four years). We first describe the composition of uninsured new mothers in the US in following
enactment of the major coverage provisions of the ACA, including their age, race or ethnicity,
citizenship, marital status, and geographic region. We also examine their socioeconomic characteristics
including income relative to the federal poverty level, education, and employment status.
We then describe several access and affordability measures. We examine unmet needs because of
cost for medical care, prescription drugs, and mental health care in the past year as well as a composite
measure of any of these unmet needs. We also consider an indicator of any delayed care because of cost
in the past 12 months and whether a mother reported being very, somewhat, or not at all worried about
paying her medical bills if she got sick or had an accident. We also examine whether new mothers
reported having a usual source of care other than the emergency department; whether they had seen a
general doctor, a specialist, an ob-gyn, or a mental health provider in the past year; and whether they
had received a flu shot. Finally, we explore how long uninsured new mothers have gone without
coverage and the reasons they report for being uninsured.
The NHIS data have several limitations. First, because mothers are identified based on the presence
of an infant in the household and there are known issues with undercounting young children in survey
data, our definition of new mothers contains measurement error. Further, we are unable to distinguish
between biological and adoptive mothers, so some new mothers in our sample may not have given birth.
Moreover, the small sample size on the NHIS does not allow us to further analyze subgroups of
uninsured new mothers, including those most likely to be eligible for an extension of postpartum
Medicaid eligibility. Finally, all information is self-reported and therefore subject to recall and social
desirability biases.
Pregnancy Risk Assessment and Monitoring System, 2015–17
To supplement our NHIS analysis, we use data from the 2015–17 PRAMS, which includes information
from new mothers in 41 states and combines information from the vital records birth certificate and a
survey of new mothers conducted two to six months after delivery.
6
The PRAMS provides a unique
opportunity to more precisely identify new mothers who lost Medicaid coverage following their
delivery. Because the PRAMS is sampled from vital records data, we faced no issues identifying new
mothers. Moreover, the survey asks women about their insurance coverage at different points during
the perinatal period, allowing us to identify a sample of women who reported having their prenatal care
THE BENEFITS OF INCREASING POSTPARTUM MEDICAID COVERAGE
5
covered by Medicaid and who report being uninsured at the time of the postpartum survey. We refer to
the period during which the survey was conducted—two to six months after delivery—as the
postpartum period when discussing the PRAMS analysis.
We examine several health measures that may indicate a mother’s elevated need for ongoing care
after giving birth. First, we examine indicators of prepregnancy obesity, hypertension, diabetes, and
depression as well as indicators of gestational diabetes and pregnancy-related hypertension, all from
the PRAMS survey. Each of these conditions can contribute to complications during pregnancy or
delivery that would require additional follow-up care, but even without serious pregnancy
complications, consistent care is required to monitor and manage these chronic conditions and maintain
good health throughout a woman’s life (Accortt, Cheadle, and Schetter 2015; Bansil et al. 2010; Blotsky
et al. 2019; Buschur, Stetson, and Barbour 2018; Dabelea et al. 2008; Kitzmiller, Dang-Kilduff, and
Taslimi 2007; James and Nelson-Piercy 2004; Jarde et al. 2016). Next, using details recorded on the
birth certificate, we examine the method of delivery, because cesarean-section deliveries may put
women at risk of hemorrhage or surgical site infection and require additional follow-up care (Burke and
Allen 2020). We also examine self-reported information from the survey about having a postpartum
checkup and responses to two questions screening for postpartum depression (Kroenke, Spitzer, and
Williams 2003). These questions ask about respondents’ frequency of feeling down, depressed, or
hopeless and about respondents’ frequency of feeling little interest or pleasure in doing things. A
postpartum checkup is recommended for all new mothers and should screen for postpartum depression
(ACOG 2018). The presence of postpartum mental health problems requires close monitoring and
treatment because these issues can become severe, and they have serious implications for both
maternal and child health (Lampard, Franckle, and Davison 2014; O’Hara and McCabe 2013).
Like the NHIS data, the PRAMS data also have some limitations. The sample is not nationally
representative, and data are missing for several large states, including California. Further, the sample of
states is not consistent across years, and some survey questions change slightly between the 2015 and
2016–17 phases. These changes may affect our measures of prepregnancy hypertension, diabetes, and
depression and of gestational diabetes and pregnancy-related hypertension. As with all survey data,
self-reported measures may suffer from recall or social desirability biases.
Results
From 2015 to 2018, approximately 11.5 percent of new mothers nationwide were uninsured (data not
shown). Fully 50.4 percent of these uninsured new mothers were Hispanic, 38.3 percent were
noncitizens, 49.6 percent had incomes below the federal poverty level, and 65.3 percent lived in the
South (table 1).
6
THE BENEFITS OF INCREASING POSTPARTUM MEDICAID COVERAGE
TABLE 1
Composition of Uninsured New Mothers, 2015–18
Percent
Standard
error
Age
19–25
31.7
2.4
26–34
51.3
2.6
35–44
17.0
2.0
Race or ethnicity
White, non-Hispanic
34.2
2.8
Black, non-Hispanic
11.5
1.8
Hispanic
50.4
3.0
Other, non-Hispanic
3.9
0.9
Citizenship status
Citizen
61.7
3.0
Noncitizen
38.3
3.0
Region
Northeast
6.2
1.3
Midwest
13.6
2.0
South
65.3
2.8
West
14.9
2.0
Marital status
Married
56.9
2.5
Lives with partner
23.6
2.3
Widowed, separated, or divorced
4.6
1.1
Never married
14.9
1.9
Education
Less than high school
34.7
2.5
High school graduate
28.1
2.4
Some college
26.2
2.5
College graduate
10.9
1.7
Tax unit income (% of FPL)
Less than 100%
49.6
2.6
100–138%
14.3
2.0
138–250%
20.1
2.4
250–400%
12.9
2.1
Above 400%
3.1
1.0
Employment status
Employed
34.0
2.4
Unemployed
7.4
1.3
Not in labor force
58.5
2.6
Number of children
1
32.1
2.8
2
29.5
2.7
3+
38.5
2.7
Source: Urban Institute analysis of 2015–18 National Health Interview Survey data.
Notes: FPL = the federal poverty level. New moms are women ages 19 to 44 with a child under age 1 whose NHIS record points to
the woman as his or her biological or adoptive mother. Uninsurance status is at the time of the survey.
Uninsured new mothers reported significant access and affordability problems. About 14.2 percent
reported an unmet need for medical care because of cost in the past year, 17.0 percent had an unmet
THE BENEFITS OF INCREASING POSTPARTUM MEDICAID COVERAGE
7
need for a prescription medicine, and about 1.9 percent reported an unmet need for mental health care
(figure 1). Around 23.2 percent of uninsured new mothers reported at least one of these unmet needs
because of cost in the past year, and 16.2 percent reported delaying medical care because of cost. Just
over half (52.1 percent) were very worried about paying their medical bills, and just under one-third
(31.4 percent) were somewhat worried.
FIGURE 1
Health Care Affordability Problems among Uninsured New Mothers, 2015–18
URBAN INSTITUTE
Source: Urban Institute analysis of 2015-2018 National Health Interview Survey data.
Notes: New moms are women ages 19 to 44 with a child under age 1 whose NHIS record points to the woman as his or her
biological or adoptive mother. Uninsurance status is at the time of the survey. All unmet needs are because of cost and refer to the
past 12 months.
Moreover, these data suggest problems with access to and use of health care among some new
mothers. Only 55.8 percent reported having a usual source of care, and although 82.2 percent had seen
an ob-gyn in the past year, only 34.1 percent received a flu shot, and just 42.0 percent saw a general
doctor (figure 2).
31.4%
52.1%
16.2%
23.2%
1.9%
17.0%
14.2%
Somewhat worried about medical bills
Very worried about medical bills
Delayed care because of cost in past 12 months
Any unmet need because of cost
Unmet need for mental health care
Unmet need for prescription medicines
Unmet need for medical care
8
THE BENEFITS OF INCREASING POSTPARTUM MEDICAID COVERAGE
FIGURE 2
Health Care Access and Use among Uninsured New Mothers, 2015–18
URBAN INSTITUTE
Source: Urban Institute analysis of 2015–18 National Health Interview Survey data.
Notes: New moms are women ages 19 to 44 with a child under age 1 whose NHIS record points to the woman as his or her
biological or adoptive mother. Uninsurance status is at the time of the survey.
TABLE 2
Duration and Reasons for Uninsurance among New Mothers, 2015–18
Percent
Standard
error
Last time insured
Past 6 months
44.7
2.8
6 months to 1 year ago
25.0
2.5
1 to 3 years ago
4.5
1.5
Over 3 years ago
4.8
1.2
Never
21.1
2.4
Reasons for being uninsured
Lost Medicaid/Medical plan stopped after pregnancy
47.4
2.8
Cost is too high 21.3 2.3
Lost job/changed employer
10.4
1.9
Divorce/separation/death of spouse/parent
0.8
0.5
Ineligible because of age/left school
3.3
1.1
Employer doesn't offer coverage/not eligible for coverage
3.2
0.8
Insurance company refused coverage 1.0 0.5
Lost Medicaid/Medical plan because of new job/income
2.8
1.1
Lost Medicaid/Medical plan, other reason
3.1
1.0
Other reasons
11.9
1.9
Source: Urban Institute analysis of 2015-2018 National Health Interview Survey data.
Notes: New moms are women ages 19 to 44 with a child under age 1 whose NHIS record points to the woman as his or her biological or
adoptive mother. Uninsurance status is at the time of the survey. Other reasons include never had coverage, moved from another
county/state/country, self-employed, no need/chooses not to have, got married, and other reason. People can report multiple reasons.
34.1%
4.7%
82.2%
11.4%
42.0%
55.8%
Received flu vaccine in past 12 months
Saw mental health provider in past 12 months
Saw OB-GYN in past 12 months
Saw medical specialist in past 12 months
Saw general doctor in past 12 months
Had a usual source of care
(other than emergency department)
THE BENEFITS OF INCREASING POSTPARTUM MEDICAID COVERAGE
9
Among these uninsured new mothers, about 44.7 percent reported having coverage in the past six
months and another 25.0 percent within the past year, so most new mothers were likely covered at
delivery and during their pregnancies (table 2). However, about 30.3 percent total reported being
uninsured for one year or more. Specifically, 4.5 percent last had coverage one to three years earlier, 4.8
percent last had coverage over three years earlier, and 21.1 percent had never been insured. When
asked why they were currently uninsured, about half reported that they lost Medicaid or other medical
coverage following pregnancy, which suggests that a postpartum extension of eligibility could benefit
many of these mothers (table 2).
In the 41 states with available PRAMS data from 2015 to 2017, 22 percent of women who received
Medicaid-covered prenatal care were uninsured two to six months after delivery, a rate that is higher in
states that did not expand Medicaid under the ACA (37 percent) than in states that expanded Medicaid
(11 percent; data not shown). Using data from the PRAMS, we further examine the health needs of
these women who lost prenatal Medicaid coverage and became uninsured in the postpartum period.
FIGURE 3
Prepregnancy and Prenatal Conditions among Women Who Had Prenatal Medicaid Coverage and
Were Uninsured Postpartum, 2015–17
URBAN INSTITUTE
Source: Urban Institute analysis of 2015-2017 Pregnancy Risk Assessment Monitoring System (PRAMS) data.
Notes: Sample includes women age 20 and over with a live birth who reported having Medicaid for prenatal care and were
uninsured two to six months after delivery. All measures are from the PRAMS survey.
a
indicates measure is only available for 2016-17.
Among those who lost Medicaid coverage and became uninsured in the postpartum period, only
small shares reported having diabetes (3.3 percent) or hypertension (5.1 percent) before pregnancy, but
about 30.6 percent were obese (figure 3). We also find that 11.4 percent of women who lost Medicaid
coverage reported gestational diabetes and, in 2016–17, 10.2 percent reported pregnancy-related
3.3%
5.1%
6.7%
30.6%
10.4%
11.4%
10.2%
18.5%
12.5%
Diabetes Hypertension Diabetes or
hypertension
Obesity Depression Gestational
diabetes
Hypertensionᵃ Diabetes or
hypertensionᵃ
Depressionᵃ
Prepregnancy conditions Prenatal conditions
10
THE BENEFITS OF INCREASING POSTPARTUM MEDICAID COVERAGE
hypertension during the prenatal period. Assessing mental health, 10.4 percent of women reported
prepregnancy depression, and in 2016–17, 12.5 percent reported depression during pregnancy.
Although 83.8 percent of women who lost Medicaid and became uninsured in the postpartum period
reported having a postpartum checkup at some point, many indicated potential needs for physical or
mental health care (figure 4). About one-third had delivered by cesarean section, indicating they could
have enhanced health needs during the recovery period, and many reported significant mental health
concerns in the postpartum period. We find that 7.5 percent reported always or often feeling depressed,
and 11.4 percent reported always or often feeling a lack of interest; rates of reporting sometimes feeling
depressed and sometimes feeling a lack of interest were both about 20 percent.
FIGURE 4
Delivery Method and Postpartum Checkup and Mental Health among Women Who Had Prenatal
Medicaid Coverage and Were Uninsured Postpartum, 2015–17
URBAN INSTITUTE
Source: Urban Institute analyses of 2015–17 Pregnancy Risk Assessment Monitoring System (PRAMS) data.
Notes: Sample includes women age 20 and over with a live birth who reported having Medicaid for prenatal care and were
uninsured two to six months after delivery. All measures are from the PRAMS survey except delivery method, which is from
infants’ birth certificates.
Discussion
Despite documented increases in insurance coverage for new mothers under the ACA, more than 1 in
10 new mothers remained uninsured from 2015 to 2018, and over half of those women were Hispanic
and nearly two-thirds lived in the South. About 1 in 5 uninsured new moms reported at least one unmet
20.0%
11.4%
19.8%
7.5%
83.8%
32.3%
Experiences postpartum lack of interest: Sometimes
Experiences postpartum lack of interest: Always or often
Experiences postpartum depression: Sometimes
Experiences postpartum depression: Always or often
Received postpartum checkup
Had a cesarean-section delivery
THE BENEFITS OF INCREASING POSTPARTUM MEDICAID COVERAGE
11
need for medical care because of cost, and over half were very worried about paying their medical bills,
emphasizing that health care affordability is a problem for many new mothers. Moreover, about half of
all uninsured new mothers reported that losing Medicaid or other coverage after pregnancy was the
reason they were uninsured. Thus, it appears many new mothers could benefit from the financial
protection that insurance can provide and would likely benefit from the extensions of postpartum
Medicaid coverage that have been proposed at both the federal and state levels.
Among women who lost Medicaid coverage and became uninsured in the postpartum period,
almost one-third were obese before their pregnancy, and 18.5 percent reported either gestational
diabetes or pregnancy-related hypertension, all of which increase risks for poor health conditions
following pregnancy and require ongoing monitoring and care. Moreover, about one-third of new moms
who lost Medicaid were recovering from a cesarean section, and just over one-quarter reported being
depressed sometimes, often, or always in the postpartum period. Although it has important implications
for maternal health, maternal depression during the year after giving birth also affects infants’
emotional and cognitive development (Center on the Developing Child at Harvard University 2009),
suggesting that closely monitoring these mothers’ mental health is critical (Pratt et al. 2017).
Altogether, although about 84 percent of those who lost Medicaid coverage and became uninsured
reported having a postpartum checkup, our findings suggest that many uninsured new mothers have
both physical and mental health needs that would benefit from ongoing care.
As part of the response to the COVID-19 pandemic, the Families First Coronavirus Response Act
requires that states maintain Medicaid coverage for those who might otherwise lose coverage because
of eligibility changes or other administrative barriers in order for those states to receive enhanced
Medicaid payments during the public health emergency (Rudowitz 2020). Thus, fewer new mothers who
have Medicaid coverage during their pregnancies may lose their coverage and face the associated
access and affordability problems described in this brief during the pandemic. Moreover, as states adapt
to this policy for the duration of the public health crisis, some states may identify and address various
challenges that could make implementation of a permanent postpartum Medicaid extension easier
when the novel coronavirus is no longer a threat.
However, the current pandemic could exacerbate some of the challenges facing uninsured new
mothers and affect insured mothers.
7
Access to routine care may be more limited because of social
distancing recommendations, stay-at home orders, associated transportation difficulties, and a lack of
available or reliable telehealth options. Further, women may be reluctant to seek needed care because
of fears of contracting the virus or burdening the health care system. Moreover, health problems,
especially mental health problems, could be worsened during the pandemic because of increased stress
and anxiety as well as the limited ability of family and community to support new parents while
complying with social distancing guidelines. Together, barriers to accessing care or new mothers’
reluctance to seek care could make it more difficult to identify postpartum health issues that require
immediate medical attention. Thus, policies to address these issues would be valuable additions to
efforts to extend postpartum insurance coverage.
12
THE BENEFITS OF INCREASING POSTPARTUM MEDICAID COVERAGE
Even if a permanent postpartum extension were adopted, however, not all uninsured new mothers
would qualify. Access to postpartum coverage under current rules depends critically on state-specific
eligibility criteria for pregnancy-related Medicaid coverage, based both on income and immigration
status and on which women actually enroll in Medicaid during their pregnancies. These same factors will
determine who is eligible for the maintenance-of-effort provisions under the Families First Coronavirus
Response Act and state-specific implementation of the provisions may vary. Moreover, the economic
downturn may extend well beyond the public health emergency, leaving many new mothers at higher
risk of being uninsured when the maintenance-of-effort provision expires or if they lose other coverage
sources because of rising unemployment. Without additional federal or state action to expand access to
affordable coverage options, many new mothers may remain uninsured both during and after the public
health crisis.
Our findings suggest that if new mothers were to gain coverage through an extension of
postpartum Medicaid eligibility, they could experience reduced affordability problems and an improved
ability to manage chronic conditions during that critical period after giving birth. However, longer-term
solutions to addressing the maternal morbidity and mortality crisis would involve achieving continuous
coverage and care throughout a woman’s reproductive years. A more comprehensive Medicaid
expansion, for example, would allow more low-income women to identify and manage their chronic
conditions, plan and support wanted pregnancies, and maintain good health to support ongoing
maternal and child well-being.
Notes
1
Katy Backes Kozhimannil, Elaine Hernandez, Dara D. Mendez, and Theresa Chapple-McGruder, “Beyond the
Preventing Maternal Deaths Act: Implementation and Further Policy Change,” Health Affairs Blog, February 4,
2019.
2
Severe Maternal Morbidity in the United States,” Centers for Disease Control and Prevention, last reviewed
January 31, 2020,
https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html.
3
Emily Eckert, “It’s Past Time to Provide Continuous Medicaid Coverage for One Year Postpartum,” Health Affairs
Blog, February 6, 2020.
4
Stacey McMorrow and Genevieve Kenney, “Despite Progress under the ACA, Many New Mothers Lack Insurance
Coverage,” Health Affairs Blog, September 19, 2018,
https://www.healthaffairs.org/do/10.1377/hblog20180917.317923/full/.
5
Stacey McMorrow, Emily M. Johnston, and Genevieve M. Kenney. 2020. “Extending Postpartum Medicaid
Coverage Beyond 60 Days Could Benefit over 200,000 Low-Income Uninsured Citizen New Mothers,” Incidental
Economist, February 4, 2020, https://theincidentaleconomist.com/wordpress/extending-postpartum-medicaid/.
6
The states are AK, AL, AR, CO, CT, DE, GA, HI, IA, IL, KS, KY, LA, MA, MD, ME, MI, MO, MT, NC, ND, NE, NH, NJ,
NM, NY, OH, OK, OR, PA, RI, SD, TN, TX, UT, VA, VT, WA, WI, WV, and WY.
7
Laurie Zephyrin, and Rachel Nuzum. “Caring for Moms During the COVID-19 Pandemic.” To the Point
(Commonwealth Fund blog), April 15, 2020, https://www.commonwealthfund.org/blog/2020/caring-moms-
during-covid-19-pandemic.
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About the Authors
Stacey McMorrow is a principal research associate in the Health Policy Center at the Urban Institute.
She has extensive experience using quantitative methods to study the factors that affect individual
health insurance coverage and access to care as well as the impacts of state and national health reforms
on employers and individuals.
Lisa Dubay is a senior fellow in the Health Policy Center and a nationally recognized expert on Medicaid
and the Children’s Health Insurance Program (CHIP). She has focused for over 25 years on evaluating
the effects of public policies on access to care, health care utilization, health outcomes, and health
insurance coverage using quasi-experimental designs. Her evaluation work has included assessing the
impact of expansions in public health insurance programs for children, pregnant women, and adults for
federal agencies and major foundations. She also developed the center’s Medicaid eligibility simulation
model, which she has used to produce estimates of eligible but uninsured children and adults, and
participation rates in Medicaid and CHIP. Dubay returned to Urban after spending a number of years as
an associate professor at the Johns Hopkins Bloomberg School of Public Health and a special advisor in
the Office of the Assistant Secretary for Planning and Evaluation at the Department of Health and
Human Services. She has an ScM from the Harvard University School of Public Health and a PhD from
Johns Hopkins University.
Genevieve M. Kenney is a senior fellow and vice president of the Health Policy Center. She has been
conducting policy research for over 25 years and is a nationally renowned expert on Medicaid, CHIP,
and broader health insurance coverage and health issues facing low-income children and families.
Kenney has led a number of Medicaid and CHIP evaluations and published over 100 peer-reviewed
journal articles and scores of briefs on insurance coverage, access to care, and related outcomes for low-
income children, pregnant women, and other adults. In her current research, she is examining
implications of the Affordable Care Act, public policies affecting receipt of treatment for opioid and
substance use disorder, and emerging policy questions related to Medicaid and CHIP. She received a
master’s degree in statistics and a PhD in economics from the University of Michigan.
Emily Johnston is a research associate in the Health Policy Center, where she studies health insurance
coverage, access to care, Medicaid and CHIP policy, and women’s and children’s health. Her research
focuses on the effects of state and federal policies on the health and well-being of vulnerable
populations. Before joining Urban, Johnston studied the role of public opinion in determining state
eligibility and program design policies for parents and children in the Medicaid and CHIP programs. She
also worked on projects related to the Affordable Care Act as a fellow in the Office of the Associate
Director for Policy at the Centers for Disease Control and Prevention. Johnston received her PhD in
health services research and health policy from Emory University.
16
THE BENEFITS OF INCREASING POSTPARTUM MEDICAID COVERAGE
Clara Alvarez Caraveo is a research assistant studying the effects of Medicaid expansion as a result of
the Affordable Care Act on maternal health and coverage trends among vulnerable populations. She
uses quantitative analysis to understand underlying trends in health and health insurance coverage to
inform policy recommendations. Alvarez Caraveo has a BA in sociology with minors in policy analysis
and management, demography, and inequality Studies from Cornell University.
Acknowledgments
Support for this brief was provided by the David and Lucile Packard Foundation and the Robert Wood
Johnson Foundation’s Policies for Action program. We are grateful to them and to all our funders, who
make it possible for Urban to advance its mission.
The views expressed are those of the authors and should not be attributed to the Urban Institute,
its trustees, or its funders. Funders do not determine research findings or the insights and
recommendations of Urban experts. Further information on the Urban Institute’s funding principles is
available at urban.org/fundingprinciples.
The authors are grateful to Tyler Thomas for assistance with the NHIS data, to Jennifer Haley for
helpful comments and suggestions, and to Michael Marazzi for editorial assistance.
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