Advertisement

National Trends in Health Insurance Coverage of Pregnant and Reproductive-Age Women, 2000 to 2009

      Abstract

      Purpose

      Health insurance facilitates financial access to health services, including prenatal and preconception care. This study characterized changes in health insurance coverage among reproductive-age women in the United States from 2000 to 2009.

      Methods

      Data from female respondents (ages 18–49) to the National Health Interview Surveys, 2000 to 2009 (n = 207,968), including those pregnant when surveyed (n = 3,204), were used in a repeated cross-sectional design. Changes over time were estimated using longitudinal regression models.

      Main Findings

      Of the reproductive-age women in this study, 25% were uninsured at some point in the prior year. Ten percent of pregnant women reported currently being uninsured, and 27% and 58% reported Medicaid coverage or private health insurance, respectively. Among women who were not pregnant, 19% were currently uninsured, 8% had Medicaid, and 68% had private coverage. From 2000 to 2009, an increasing percentage of reproductive-age women reported having gone without health insurance in the past year. Controlling for sociodemographic and health variables, the chances that a reproductive-age woman had been uninsured increased by approximately 1.5% annually (p < .001), and did not differ between pregnant women and those who were not pregnant. The odds that an insured pregnant woman had Medicaid coverage increased 7% per year over the study period (p < .001), whereas the odds of private coverage decreased.

      Conclusion

      Reproductive-age women are increasingly at risk of being uninsured, which raises concerns about access to prenatal and preconception care. Among pregnant women, access to private health insurance has decreased, and state Medicaid programs have covered a growing percentage of women. Health reform will likely impact future trends.

      Introduction

      The public health importance of access to health care for reproductive-age women, including preconception and prenatal care, has motivated national goal setting as well as policy agendas and discussions (
      • Rosenbaum S.
      Women and health insurance: Implications for financing preconception health.
      ,
      U.S. Department of Health and Human Services (DHHS)
      Healthy people 2020 topics and objectives: Maternal, infant and child health.
      ). Starting in 1991, all state Medicaid programs were required to cover pregnant women with incomes below 133% of the federal poverty level (FPL), and by 2008, 20 states covered pregnant women up to at least 200% of the FPL (
      • Glied S.
      • Jack K.
      • Rachlin J.
      Women’s health insurance coverage 1980-2005.
      ,

      Kaiser Family Foundation. (2010a). Medicaid/SCHIP Income eligibility for pregnant women, by state, 2008. Available: www.statehealthfacts.org. Accessed June 30, 2011.

      ). As of 2005, 41% of all births in the United States were financed through Medicaid (

      Kaiser Family Foundation. (2010b). Fact sheet: women’s health insurance coverage. Available: http://www.kff.org. Accessed June 30, 2011.

      ). There have been recent policy efforts to expand health insurance coverage for pregnant and reproductive-age women through state Medicaid programs, the Children’s Health Insurance Program Reauthorization Act of 2009, and incentives and structures introduced in the context of the Affordable Care Act (ACA) of 2010 (
      • Howell E.M.
      The impact of the Medicaid expansions for pregnant women: a synthesis of the evidence.
      ,
      • Johnson K.A.
      Women’s health and health reform: implications of the Patient Protection and Affordable Care Act.
      ,
      • Markus A.R.
      • Rosenbaum S.
      The role of Medicaid in promoting access to high-quality, high-value maternity care.
      ,
      • Sakala C.
      U.S. health care reform legislation offers major new gains to childbearing women and newborns.
      ). Key provisions of the ACA most likely to affect health insurance coverage for women of reproductive-age include Medicaid expansions to cover low-income individuals (<133% FPL), state-based exchanges for the purchase of private health insurance with premium subsidies for those between 133% and 400% FPL, zero cost-sharing for certain preventive services including prenatal visits, elimination of preexisting condition exclusions, and an individual mandate to purchase health insurance. (

      Kaiser Family Foundation. (2010b). Fact sheet: women’s health insurance coverage. Available: http://www.kff.org. Accessed June 30, 2011.

      ,
      • Johnson K.A.
      Women’s health and health reform: implications of the Patient Protection and Affordable Care Act.
      ,
      • Sakala C.
      U.S. health care reform legislation offers major new gains to childbearing women and newborns.
      ).
      The past decade has seen a general rise in rates of uninsurance and a decline in private health insurance and employer-sponsored coverage (
      • DeNavas-Walt C.
      • Proctor B.D.
      • Smith J.C.
      Income, poverty, and health insurance coverage in the United States: 2009.
      ,

      Kaiser Family Foundation and Health Research and Educational Trust. (2010). Employer Health Benefits: 2010 Annual Survey. Available: http://ehbs.kff.org. Accessed June 30, 2011.

      ). However, the extent to which pregnant and reproductive-age women have been affected has not been documented. The most recent study of trends in health insurance among American women showed an increasing rate of uninsurance, growing from 11.7% in 1980 to 18.2% in 2005 among women ages 25 to 64 (
      • Glied S.
      • Jack K.
      • Rachlin J.
      Women’s health insurance coverage 1980-2005.
      ). More recent data on changes in health insurance coverage, as well as analyses focusing specifically on pregnant women, are lacking.
      Health insurance provides childbearing women with greater financial access to timely care before and during pregnancy, which promotes the health and well-being of mothers and their babies (
      U.S. Centers for Disease Control and Prevention (CDC)
      Recommendations to improve preconception health and health care—United States: A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care.
      ). Lack of health insurance can be a barrier to accessing appropriate care for pregnant and childbearing women; it can lead to delays, forgone care, and poor health outcomes (
      • Hadley J.
      Sicker and poorer—The consequences of being uninsured: A review of the research on the relationship between health insurance, medical care use, health, work, and income.
      ,
      • Kaestner R.
      Health insurance, the quantity and quality of prenatal care, and infant health.
      ,
      • Oberg C.N.
      • Lia-Hoagberg B.
      • Skovholt C.
      • Hodkinson E.
      • Vanman R.
      Prenatal care use and health insurance status.
      ).
      This paper examines recent trends in health insurance coverage among women of reproductive age (ages 18–49) in the United States, with particular attention paid to changes occurring in health insurance coverage of pregnant women. Our goal was to characterize pre-health reform trends in health insurance for reproductive-age women, including those who are pregnant, and to understand the implications of prior trends for the implementation of the ACA.

      Methods

      This study used recent (2000–2009), nationally representative survey data in a repeat, cross-sectional design to examine changes over time in health insurance coverage among pregnant and reproductive-age women.

      Data and Study Population

      The study population was drawn from the Integrated Health Interview Series (IHIS), a web-based harmonization of data from the U.S. National Health Interview Surveys (NHIS), which are conducted annually by the CDC among a population-based, representative sample of noninstitutionalized Americans (

      Integrated Health Interview Series (IHIS): Version 3.0. (2010). Minneapolis: Minnesota Population Center and State Health Access Data Assistance Center, University of Minnesota. Available: http://www.ihis.us/ihis.

      ). Detailed information about the survey methodology, variable measurement, and data harmonization is available on the IHIS website (http://www.ihis.us/ihis). These data have been successfully used in epidemiologic and health services research to document trends in health behaviors and health care utilization. The IHIS data are also useful for conducting policy-relevant, longitudinal analyses of health-related outcomes (
      • Johnson P.J.
      • Blewett L.A.
      • Ruggles S.
      • Davern M.E.
      • King M.L.
      Four decades of population health data: the Integrated Health Interview Series as and epidemiologic resource.
      ). We analyzed survey responses from 2000 to 2009 from all female participants ages 18 to 49 (n = 207,968), including those who reported being pregnant at the time of the survey (n = 3,204).

      Variable Measurement

      Health insurance coverage was measured from both current and retrospective perspectives. Survey respondents were asked whether they currently had health insurance on the date the survey was administered, and they were also asked to identify the type of insurance coverage they had. We categorized respondents as either insured or uninsured, and among those with health insurance, we created indicator variables for whether the respondent reported Medicaid coverage or private health insurance. We also created a variable to indicate whether the respondent reported currently having access to health insurance at work. Survey respondents with insurance coverage were also asked about having experienced any time without health insurance over the past year, and we created a variable to indicate whether a respondent was either currently uninsured or reported having been uninsured at any point in the year before responding to the survey.
      During the survey administration, female respondents were asked whether they were currently pregnant. Thus, we were able to distinguish pregnant women from nonpregnant women. However, the survey did not collect information on other pregnancy-related variables such as gestational age.
      We included the following variables as demographic or socioeconomic controls, because they are associated with health insurance access and coverage: Age (in years), U.S. citizenship, race, ethnicity, marital status, family size, level of educational attainment, employment status, family income below the FPL, health status, and region of the country. Variables were constructed based on respondents’ self-reports at the time of the survey and have been used in prior research utilizing NHIS and IHIS survey data (
      • Blewett L.A.
      • Johnson P.J.
      • Mach A.L.
      Immigrant children’s access to health care: differences by global region of birth.
      ,
      • Johnson P.J.
      • Blewett L.A.
      • Ruggles S.
      • Davern M.E.
      • King M.L.
      Four decades of population health data: the Integrated Health Interview Series as and epidemiologic resource.
      ). Although all race and ethnicity categories are included in statistical analyses, fewer than 5% of all women in the sample identified themselves as Asian, Native American/American Indian, multiracial, and other. Thus, sample size was not sufficient for calculation of statistically meaningful differences among these racial groups. Results for Black (vs. White) race and Hispanic (vs. not Hispanic) ethnicity are shown in Table 1, Table 2.
      Table 1Descriptive Statistics for U.S. Women (Aged 18–49), 2000 to 2009
      Pregnant Women (n = 3,204)Women Who are Not Pregnant (n = 204,764)
      n%n%
      Outcomes = health insurance status
       Ever uninsured (in past year)7932549,81724
       Currently uninsured3291039,47319
       Currently insured through Medicaid8542716,9018
       Currently privately insured1,85358139,09268
       Currently offered health insurance at work1,2633993,51846
      Covariates
       Age (yrs)
      <259963142,73821
      25–299452929,36514
      30–347742430,12515
      ≥3549015102,53650
      Race/ethnicity
       Hispanic6001929,74915
       Black4911528,47814
      ≥4-Person family9493091,28545
      Married2,18068110,57754
      Working1,70853137,38667
      U.S. citizen2,75886183,08789
      Education
       Less than high school5601725,83313
       High school1,60050112,12855
       College6211937,90619
       Graduate degree299914,9107
      Poor or bad health139414,8957
      Family income below the federal poverty level5151621,57611
      Region
       Northeast5491737,41918
       North central7672448,39524
       South1,2263874,85337
       West6622142,27821
      Table 2Results from Logistic Regression Models for Current Health Insurance Status among Pregnant Women (n = 3,204) from 2000 to 2009
      Currently UninsuredCurrently Covered by Medicaid (Conditional on Having Insurance; n = 2,785)
      OR95% CIOR95% CI
      Trend over time (annual)
       Year (2000–2009)0.970.91–1.031.071.02–1.120
      p < .01.
      Demographic characteristics
       Age (in years)1.000.98–1.010.940.91–0.960
      p < .001.
       Hispanic (vs. non-Hispanic)1.551.15–2.10
      p < .01.
      1.320.89–1.97
       Black (vs. White)1.020.57–1.811.120.80–1.59
       Family of ≥40.750.63–0.90
      p < .01.
      1.410.56–3.51
       Married (vs. not married)0.750.56–1.00
      p < .05.
      0.230.18–0.31
      p < .001.
       Working (vs. not working)0.790.74–0.85
      p < .001.
      0.400.35–0.46
      p < .001.
       US citizen0.260.18–0.37
      p < .001.
      0.570.37–0.89
      p < .05.
       High school (vs. less than high school)0.730.61–0.87
      p < .05.
      0.600.39–0.92
      p < .05.
       College (vs. less than high school)0.340.25–0.47
      p < .001.
      0.130.10–0.18
      p < .001.
       Graduate degree (vs. less than high school)0.100.04–0.26
      p < .001.
      0.170.09–0.31
      p < .001.
       North Central (vs. North East)1.480.52–4.181.040.67–1.59
       South (vs. North East)2.161.09–4.31
      p < .05.
      1.120.65–1.91
       West (vs. North East)1.250.60–2.601.090.92–1.29
      p < .001.
       Self-reported fair or poor health0.510.39–0.66
      p < .001.
      1.601.06–2.41
      p < .05.
       Family income less than the federal poverty level1.371.05–1.79
      p < .05.
      6.306.06–6.55
      p < .001.
      p < .01.
      p < .001.
      p < .05.

      Statistical Analysis

      We calculated descriptive statistics to characterize the study population and presented differences between pregnant women and those of reproductive age who were not pregnant. Changes over time were estimated using a series of regression models for whether the respondent reported going without health insurance at any time in the past 12 months, whether she was currently insured, and whether health insurance was available to her through work. These regressions were conducted using generalized linear models with a logit link, given the dichotomous outcomes under study in this analysis, and we modeled longitudinal change over time by year (
      • Fitzmaurice G.M.
      • Laird N.M.
      • Ware J.H.
      Applied longitudinal analysis.
      ). Conditional regression models were used to estimate changes over time in the odds of Medicaid coverage versus private insurance among women who reported being insured.
      Sampling weights were used in analysis to reflect the survey methodology, and weights were adjusted to account for pooling 10 years of data. We estimated regression models for key outcomes for pregnant women and for nonpregnant women separately. To compare trends for pregnant women with reproductive-age women who were not pregnant, we estimated models with interaction terms to test whether patterns of insurance coverage over time differed between the two groups.

      Results

      Of the pregnant women in this study, 10% reported currently being uninsured, whereas 27% and 58% reported Medicaid coverage or private health insurance, respectively (Table 1). Nearly 40% were offered health insurance coverage at work. On average, over the past decade, about 25% of pregnant women in this study were either currently uninsured or uninsured at some point in the prior year. This figure was nearly the same for reproductive-age American women who were not pregnant (24%).
      Among 18- to 49-year-old women who were not pregnant, 19% had no health insurance, 8% had Medicaid coverage, and 68% had private coverage. Approximately 46% received an offer of health insurance from their employer. Demographic and socioeconomic characteristics that were broadly similar among pregnant and nonpregnant women included race/ethnicity, citizenship status, educational attainment, and region of the country. Pregnant women were, on average, younger, more likely to be married, have smaller families, and less likely to be working than women who were not pregnant. Pregnant women were more likely than nonpregnant women to have a family income less than the FPL, but nonpregnant women more often reported being in poor or fair health.
      Unadjusted trends over time in current health insurance status are shown in Figure 1, and distinguish between pregnant women (solid lines) and those who were not pregnant (dashed lines). There are differences in both levels and trends of coverage, with lower overall levels of private coverage and of uninsurance among pregnant women and higher levels of Medicaid coverage among pregnant women, compared with women who were not pregnant. Both pregnant and nonpregnant women saw declines in private health insurance coverage, but pregnant women reported increases over time in Medicaid coverage (although this remained steady for nonpregnant women), and no changes in current uninsurance (which increased for nonpregnant women).
      Figure thumbnail gr1
      Figure 1Trends (2000–2009) in current health insurance coverage among U.S. women ages 18 to 49, stratified by pregnancy status.
      After controlling for age, citizenship, race, ethnicity, family size, marital status, education, health status, poverty, employment, and region of the country, trends identified in Figure 1 were examined for significance. Table 2 presents the results from adjusted regression models for current health insurance status among pregnant women. The odds that a pregnant woman was uninsured do not change over the study period. Our data indicate that Hispanic women, those living in the South (relative to the North East), and those with a family income below the FPL have increased odds of uninsurance. Factors that indicate a higher likelihood of having health insurance among pregnant women include large family size (≥4), being married, working, U.S. citizenship, and having higher levels of education.
      Among pregnant women with insurance, the odds of being currently insured by Medicaid increased by 7% per year over the study period (p < .001). Younger, unmarried women, those who were not working, non-citizens, those with less education, those in fair or poor health, and those with family income less than the FPL were more likely to have Medicaid coverage during their pregnancy (relative to private coverage).
      Some women have access to employer-sponsored health insurance, either through their own job or through a spouse. In this analysis, data were not available on access to employer-sponsored health insurance through spousal coverage. The availability of employer-based health insurance through their own jobs decreased over the study period for all reproductive-age women. A lower percentage of pregnant women reported being currently employed (53% vs. 67% of nonpregnant women), and thus fewer had health insurance available to them through their own employer. The trends over time in access to health insurance through work were similar for women who were pregnant and those who were not. Women’s access to health insurance through their employers fell from 38% in 2000 to 34% in 2009 among pregnant women and from 46% to 41% among nonpregnant women (results not shown).
      From 2000 to 2009, there was an increasing trend in the percentage of women of reproductive age who reported having gone without health insurance at some point in the past year (Figure 2). Controlling for demographic and socioeconomic variables, the chances that an 18- to 49-year-old woman either was or had been uninsured increased 1.5% annually (p < .001) over the study period; this trend was not different for those who were pregnant compared with those who were not. Among expectant mothers who reported having been uninsured at some point in the previous year, the chances of being currently insured by Medicaid increased (3% annually), although the change was not significant at conventional levels, and the sample size was limited for this estimation.
      Figure thumbnail gr2
      Figure 2Trends (2000–2009) in the percentage of U.S. women (ages 18–49) who reported being currently or formerly uninsured in the past year, stratified by pregnancy status.

      Discussion

      A number of striking findings emerged from this analysis. Approximately 1 in 4 women of childbearing age reported currently being or having been uninsured at some point in the past 12 months, and this number grew over the past decade. Rates of uninsurance have risen in recent years among all reproductive-age women, including those who were uninsured before pregnancy. This represents a significant potential barrier to accessing appropriate prenatal and preconception care (
      • Egerter S.
      • Braveman P.
      • Marchi K.
      Timing of insurance coverage and use of prenatal care among low-income women.
      ;
      • Rosenbaum S.
      Women and health insurance: Implications for financing preconception health.
      ,
      • Wise P.H.
      Transforming preconceptional, prenatal, and interconceptional care into a comprehensive commitment to women’s health.
      ) Trends in prior uninsurance seemed to diverge slightly (although not significantly) between pregnant and nonpregnant women during 2006 and 2007. This is likely owing to random sampling variation; we identified no major policy interventions that would have produced such a shift. However, these trends may have contributed to national efforts to highlight the importance of preconception care (
      • Rosenbaum S.
      Women and health insurance: Implications for financing preconception health.
      ,
      • Wise P.H.
      Transforming preconceptional, prenatal, and interconceptional care into a comprehensive commitment to women’s health.
      ). Overall, the growing number of reproductive-age women who experienced uninsurance is concerning; however, it is consistent with prior research. Our findings reflect similar published results which estimate the percentage of adult women under 65 without health insurance at 18.2% in 2005 and 17% in 2008; further, in 2008, 24% of all women ages 18 to 64 reported having gone without insurance at some point in the prior year (
      • Glied S.
      • Jack K.
      • Rachlin J.
      Women’s health insurance coverage 1980-2005.
      ,

      Ranji, U., & Salganicoff, A. (2011). Women’s health care chartbook: Key findings from the Kaiser Women’s Health Survey: Kaiser Family Foundation. Available: http://www.kff.org/. Accessed June 30, 2011.

      ).
      Although there is great variability in eligibility and enrollment procedures, coverage policies, and benefits structures across state Medicaid programs and over time (
      • Heberlein M.
      • Brooks T.
      • Guyer J.
      • Artiga S.
      • Stephens J.
      Holding steady, looking ahead: Annual findings of a 50-state survey of eligibility rules, enrollment and renewal procedures, and cost sharing practices in Medicaid and CHIP, 2010-2011.
      ,

      Kaiser Family Foundation. (2010a). Medicaid/SCHIP Income eligibility for pregnant women, by state, 2008. Available: www.statehealthfacts.org. Accessed June 30, 2011.

      ,

      Ranji, U., Salganicoff, A., Stewart, A. M., Cox, M., & Doamekpor, L. (2009). State Medicaid coverage of perinatal health services summary of state survey findings: Kaiser Family Foundation and the George Washington University Medical Center School of Public Health. Available: http://www.kff.org. Accessed November 29, 2011.

      ), our analysis indicates that state Medicaid programs have been increasingly covering pregnant women, including those who reported having previously been uninsured. Table 3 presents examples of state-level Medicaid policies that affect insurance coverage for pregnant and reproductive-age women and information on variations in state adoption of such policies. Particularly influential policies are summarized briefly below and described in depth elsewhere. (See, for example,
      • Heberlein M.
      • Brooks T.
      • Guyer J.
      • Artiga S.
      • Stephens J.
      Holding steady, looking ahead: Annual findings of a 50-state survey of eligibility rules, enrollment and renewal procedures, and cost sharing practices in Medicaid and CHIP, 2010-2011.
      ,
      • Hill I.
      • Hogan S.
      • Palmer L.
      • Courtot B.
      • Gehshan S.
      • Belnap D.
      • et al.
      Medicaid outreach and enrollment for pregnant women: what is the state of the art?.
      ,

      Ranji, U., Salganicoff, A., Stewart, A. M., Cox, M., & Doamekpor, L. (2009). State Medicaid coverage of perinatal health services summary of state survey findings: Kaiser Family Foundation and the George Washington University Medical Center School of Public Health. Available: http://www.kff.org. Accessed November 29, 2011.

      ). As a condition for receiving federal matching dollars, state Medicaid programs are required to cover pregnant women up to at least 133% FPL, but some states currently cover pregnant women up to 300% FPL (

      Kaiser Family Foundation. (2011a). Income eligibility limits for pregnant women as a percent of federal poverty level (FPL), January 2011. Available: www.statehealthfacts.org. Accessed November 29, 2011.

      ). Income eligibility levels for pregnant women are determined by states and have generally remained steady or increased slightly over the past decade. Eligible women are required to enroll in Medicaid to receive benefits, and some states have recently created policies to simplify enrollment procedures for pregnant women (
      • Hill I.
      • Hogan S.
      • Palmer L.
      • Courtot B.
      • Gehshan S.
      • Belnap D.
      • et al.
      Medicaid outreach and enrollment for pregnant women: what is the state of the art?.
      ,

      Ranji, U., Salganicoff, A., Stewart, A. M., Cox, M., & Doamekpor, L. (2009). State Medicaid coverage of perinatal health services summary of state survey findings: Kaiser Family Foundation and the George Washington University Medical Center School of Public Health. Available: http://www.kff.org. Accessed November 29, 2011.

      ). However, the number of states that have increased outreach efforts and/or offered enhanced maternal benefits packages has declined slightly since the 1990s (
      • Hill I.
      • Hogan S.
      • Palmer L.
      • Courtot B.
      • Gehshan S.
      • Belnap D.
      • et al.
      Medicaid outreach and enrollment for pregnant women: what is the state of the art?.
      ). Our analysis indicated a relative increase in Medicaid coverage reported by pregnant women, compared with similar women who are not pregnant. This finding is consistent with recent efforts to expand access to state Medicaid programs for pregnant women (through increased income eligibility or simplified enrollment) as well as greater numbers of women qualifying via income eligibility owing to the recent economic recession (

      Kaiser Family Foundation. (2010b). Fact sheet: women’s health insurance coverage. Available: http://www.kff.org. Accessed June 30, 2011.

      ,
      • Markus A.R.
      • Rosenbaum S.
      The role of Medicaid in promoting access to high-quality, high-value maternity care.
      ).
      Table 3Selected State-Level Medicaid Policy Decisions that May Impact Health Insurance Coverage for Pregnant and Reproductive-Age Women
      Source: Ranji, U., Salganicoff, A., Stewart, A.M., Cox, M., Doamekpor, L. (2009). State Medicaid Coverage of Perinatal Health Services Summary of State Survey Findings: Kaiser Family Foundation and the George Washington University Medical Center School of Public Health. Available at: http://www.kff.org/womenshealth/upload/8014.pdf
      2009 Status Across Surveyed States
      Eligibility
       Income eligibility limit for pregnant women (% FPL)Range, 133%–300% FPL
      Enrollment
       No asset test36/44 states and DC
       Continuous coverage through 60 days postpartum42/44 states and DC
       Presumptive eligibility25/44 states and DC
      Application
       Short application form35/44 states and DC
       Forms accepted at alternate sites49/44 states and DC
       Eligibility workers at alternate sites31/44 states and DC
       Combined application form37/44 states
       Mail-in application39/44 states and DC
       Multilingual forms36/44 states and DC
      Abbreviation: FPL, federal poverty level.
      A woman’s eligibility for Medicaid coverage as a result of pregnancy ends 60 days after delivery, and as such, many women move in and out of insurance coverage, a process often described as “churning” (

      Ranji, U., Salganicoff, A., Stewart, A. M., Cox, M., & Doamekpor, L. (2009). State Medicaid coverage of perinatal health services summary of state survey findings: Kaiser Family Foundation and the George Washington University Medical Center School of Public Health. Available: http://www.kff.org. Accessed November 29, 2011.

      ,
      • Sommers B.D.
      • Rosenbaum S.
      Issues in health reform: How changes in eligibility may move millions back and forth between Medicaid and insurance exchanges.
      ). Although this phenomenon is not directly studied in our analysis, the discrepancy between the percentage of pregnant women who reported prior uninsurance (25%) and the percentage of pregnant women who reported currently having no insurance (10%) is consistent with the concept of “churning.”
      Not surprisingly, we identified declines in private health insurance coverage and availability of employer-sponsored coverage for reproductive-age women in the United States, consistent with those reported for the general population (

      Kaiser Family Foundation and Health Research and Educational Trust. (2010). Employer Health Benefits: 2010 Annual Survey. Available: http://ehbs.kff.org. Accessed June 30, 2011.

      ).
      Although our study makes use of a rich, unique data source, secondary analysis of survey data is subject to a number of important limitations, based on data availability and measurement. Although we were able to identify pregnant women in the study, the NHIS survey did not collect specific information related to gestational age or maternity-related care that may be relevant for enhancing interpretation of the changes in health insurance coverage documented in this analysis. People under age 18 are not included in the NHIS survey, and it does not collect data on whether an individual has health insurance through a spouse. Also, imputation techniques are used by IHIS for some income data, and policy analysis was challenging because available income data do not correspond directly with FPL designations or associated policy aspects of the ACA. On balance, however, the strengths of sample size and national representativeness outweigh the limitations of the data source in allowing examination of health insurance trends among reproductive-age women.

      Policy Implications

      Our findings reveal important differences in levels and trends of health insurance coverage between pregnant and nonpregnant women of reproductive age. Due in part to eligibility for state Medicaid programs, pregnant women were more insulated from rising rates of uninsurance owing to general declines in private coverage. However, the magnitude and trends in the number of all reproductive-age women (regardless of current pregnancy status) who report being uninsured or having gone without health insurance in the prior year is troubling.
      Recognizing that half of pregnancies in the United States are unplanned or mistimed, the federal preconception care initiative aims to reach all women of reproductive age, regardless of their pregnancy intentions (
      U.S. Centers for Disease Control and Prevention (CDC)
      Recommendations to improve preconception health and health care—United States: A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care.
      ). Although changes to insurance access after health reform are likely to affect pregnant and nonpregnant groups differently, future increases in health insurance coverage facilitated by the ACA may potentially contribute to broad improvements in maternal and reproductive health, given the established connection between coverage and access to services (
      • Hadley J.
      Sicker and poorer—The consequences of being uninsured: A review of the research on the relationship between health insurance, medical care use, health, work, and income.
      ,
      • Kaestner R.
      Health insurance, the quantity and quality of prenatal care, and infant health.
      ).
      An important potential benefit of the ACA is that it will likely mitigate rising trends in uninsurance among reproductive-age women. The creation of an income floor for Medicaid eligibility may lead to improved continuity of Medicaid coverage for low-income women between pregnancies, including those who previously may have lost access to coverage after childbirth (
      • Johnson K.A.
      Women’s health and health reform: implications of the Patient Protection and Affordable Care Act.
      ,
      • Sakala C.
      U.S. health care reform legislation offers major new gains to childbearing women and newborns.
      ). State-based exchanges, preexisting condition exclusions, and subsidies may offer new private coverage options to pregnant and reproductive-age women, and preventive services coverage requirements may enhance available benefits for this population. For example, the ACA includes provisions that went into effect in 2010 to eliminate cost sharing for certain preventive services, including well-woman visits and support for breastfeeding (

      Kaiser Family Foundation. (2011b). Preventive services covered by private health plans under the Affordable Care Act, September 2011. Available: http://www.kff.org. Accessed December 7, 2012.

      ). Starting in 2012, new health plans will additionally cover a wide range of women’s preventive services, including FDA-approved prescription contraceptives and screening for sexually transmitted infections, gestational diabetes, and intimate partner violence (

      Kaiser Family Foundation. (2011b). Preventive services covered by private health plans under the Affordable Care Act, September 2011. Available: http://www.kff.org. Accessed December 7, 2012.

      ).
      While the ACA attempts to increase access to health insurance and improve the health of Americans, there are a few notable issues and exceptions that affect reproductive-age women. Undocumented immigrants are not eligible for Medicaid or premium subsidies under the ACA. An estimated 340,000 women without authorized legal status give birth every year in the United States, and the potential challenges presented by this issue will affect some states considerably more than others (
      • Passell J.S.
      • Taylor P.
      Unauthorized immigrants and their U.S.-born children.
      ). Further, it is likely that some women of reproductive age will remain uninsured after ACA implementation because coverage is unaffordable to them. For example, this could occur because their incomes do not qualify them for federal or state premium subsidies or because they have an offer of health insurance through their employer, but the out-of-pocket premiums are not perceived to be affordable. Under reform, each state’s Medicaid program will still have differential eligibility criteria for pregnant women. Logistical challenges presented by changes in eligibility or coverage status and “churning” between or among public and private plans may persist as reproductive-age women and others may move more frequently between Medicaid programs and insurance offered through state-based exchanges (
      • Sommers B.D.
      • Rosenbaum S.
      Issues in health reform: How changes in eligibility may move millions back and forth between Medicaid and insurance exchanges.
      ). Clinicians who care for pregnant and reproductive-age women should be aware of these issues and how they may affect the patient populations they serve, and policy makers ought to ensure that monitoring and evaluation of the ACA include examination of potential unintended consequences for this population.
      Careful attention is required, as ACA implementation progresses, to ensure access to appropriate preconception and prenatal health care services. A preponderance of evidence supports the role of prenatal care conferring important maternal and infant health benefits, including reduction of perinatal mortality (
      • Alexander G.R.
      • Kotelchuck M.
      Assessing the role and effectiveness of prenatal care: history, challenges, and directions for future research.
      ,
      • Fiscella K.
      Does prenatal care improve birth outcomes? A critical review.
      ). For example, infants born to mothers who received no prenatal care have lower birth weights and higher rates of admission to neonatal intensive care units (
      • Friedman S.H.
      • Heneghan A.
      • Rosenthal M.
      Disposition and health outcomes among infants born to mothers with no prenatal care.
      ). Care before pregnancy is also critically important for maternal and infant health (
      • Atrash H.K.
      • Johnson K.
      • Adams M.
      • Cordero J.F.
      • Howse J.
      Preconception care for improving perinatal outcomes: the time to act.
      ). Preconception care is an increasing focus of clinical and policy attention, including consideration of the importance of insurance coverage in facilitating access to care (
      U.S. Centers for Disease Control and Prevention (CDC)
      Recommendations to improve preconception health and health care—United States: A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care.
      ,
      • Rosenbaum S.
      Women and health insurance: Implications for financing preconception health.
      ). Policymakers and clinicians who care for reproductive-age women should be aware of changing patterns in access to health insurance and periods of uninsurance and how this may impact timely and appropriate prenatal and preconception care. Continuous monitoring of insurance trends among reproductive-age and pregnant women will be critical to understanding how changes in health insurance regulations, access, benefits, and mandates affect this population.

      References

        • Alexander G.R.
        • Kotelchuck M.
        Assessing the role and effectiveness of prenatal care: history, challenges, and directions for future research.
        Public Health Reports. 2001; 116: 306
        • Atrash H.K.
        • Johnson K.
        • Adams M.
        • Cordero J.F.
        • Howse J.
        Preconception care for improving perinatal outcomes: the time to act.
        Maternal and Child Health Journal. 2006; 10: 3-11
        • Blewett L.A.
        • Johnson P.J.
        • Mach A.L.
        Immigrant children’s access to health care: differences by global region of birth.
        Journal of Health Care for the Poor and Underserved. 2010; 21: 13-31
        • DeNavas-Walt C.
        • Proctor B.D.
        • Smith J.C.
        Income, poverty, and health insurance coverage in the United States: 2009.
        US Census Bureau, Washington, DC2010 (Available:) (Accessed June 30, 2011)
        • Egerter S.
        • Braveman P.
        • Marchi K.
        Timing of insurance coverage and use of prenatal care among low-income women.
        American Journal of Public Health. 2002; 92: 423-427
        • Fitzmaurice G.M.
        • Laird N.M.
        • Ware J.H.
        Applied longitudinal analysis.
        John Wiley & Sons, Inc, Hoboken, NJ2004
        • Fiscella K.
        Does prenatal care improve birth outcomes? A critical review.
        Obstetrics & Gynecology. 1995; 85: 468-479
        • Friedman S.H.
        • Heneghan A.
        • Rosenthal M.
        Disposition and health outcomes among infants born to mothers with no prenatal care.
        Child Abuse & Neglect. 2009; 33: 116-122
        • Glied S.
        • Jack K.
        • Rachlin J.
        Women’s health insurance coverage 1980-2005.
        Women’s Health Issues. 2008; 18: 7-16
        • Hadley J.
        Sicker and poorer—The consequences of being uninsured: A review of the research on the relationship between health insurance, medical care use, health, work, and income.
        Medical Care Research and Review. 2003; 60: 3S-75S
        • Heberlein M.
        • Brooks T.
        • Guyer J.
        • Artiga S.
        • Stephens J.
        Holding steady, looking ahead: Annual findings of a 50-state survey of eligibility rules, enrollment and renewal procedures, and cost sharing practices in Medicaid and CHIP, 2010-2011.
        Kaiser Commission on Medicaid and the Uninsured, 2011 (Publication No 8130. Available:) (Accessed November 29, 2011)
        • Hill I.
        • Hogan S.
        • Palmer L.
        • Courtot B.
        • Gehshan S.
        • Belnap D.
        • et al.
        Medicaid outreach and enrollment for pregnant women: what is the state of the art?.
        Urban Institute and the National Academy for State Health Policy, 2009 (Available:) (Accesssed November 29, 2011)
        • Howell E.M.
        The impact of the Medicaid expansions for pregnant women: a synthesis of the evidence.
        Medical Care Research and Review. 2001; 58: 3-30
      1. Integrated Health Interview Series (IHIS): Version 3.0. (2010). Minneapolis: Minnesota Population Center and State Health Access Data Assistance Center, University of Minnesota. Available: http://www.ihis.us/ihis.

        • Johnson K.A.
        Women’s health and health reform: implications of the Patient Protection and Affordable Care Act.
        Current Opinion in Obstetrics and Gynecology. 2010; 22 (492–297)
        • Johnson P.J.
        • Blewett L.A.
        • Ruggles S.
        • Davern M.E.
        • King M.L.
        Four decades of population health data: the Integrated Health Interview Series as and epidemiologic resource.
        Epidemiology. 2008; 19: 872-875
        • Kaestner R.
        Health insurance, the quantity and quality of prenatal care, and infant health.
        Inquiry. 1999; 36: 162
      2. Kaiser Family Foundation and Health Research and Educational Trust. (2010). Employer Health Benefits: 2010 Annual Survey. Available: http://ehbs.kff.org. Accessed June 30, 2011.

      3. Kaiser Family Foundation. (2010a). Medicaid/SCHIP Income eligibility for pregnant women, by state, 2008. Available: www.statehealthfacts.org. Accessed June 30, 2011.

      4. Kaiser Family Foundation. (2010b). Fact sheet: women’s health insurance coverage. Available: http://www.kff.org. Accessed June 30, 2011.

      5. Kaiser Family Foundation. (2011a). Income eligibility limits for pregnant women as a percent of federal poverty level (FPL), January 2011. Available: www.statehealthfacts.org. Accessed November 29, 2011.

      6. Kaiser Family Foundation. (2011b). Preventive services covered by private health plans under the Affordable Care Act, September 2011. Available: http://www.kff.org. Accessed December 7, 2012.

        • Markus A.R.
        • Rosenbaum S.
        The role of Medicaid in promoting access to high-quality, high-value maternity care.
        Women’s Health Issues. 2010; 20: S67-S78
        • Oberg C.N.
        • Lia-Hoagberg B.
        • Skovholt C.
        • Hodkinson E.
        • Vanman R.
        Prenatal care use and health insurance status.
        Journal of Health Care for the Poor and Underserved. 2010; 2: 270-292
        • Passell J.S.
        • Taylor P.
        Unauthorized immigrants and their U.S.-born children.
        Pew Hispanic Center. Pew Research Center, Washington, DC2010 (Available:) (Accessed December 7, 2012)
      7. Ranji, U., Salganicoff, A., Stewart, A. M., Cox, M., & Doamekpor, L. (2009). State Medicaid coverage of perinatal health services summary of state survey findings: Kaiser Family Foundation and the George Washington University Medical Center School of Public Health. Available: http://www.kff.org. Accessed November 29, 2011.

      8. Ranji, U., & Salganicoff, A. (2011). Women’s health care chartbook: Key findings from the Kaiser Women’s Health Survey: Kaiser Family Foundation. Available: http://www.kff.org/. Accessed June 30, 2011.

        • Rosenbaum S.
        Women and health insurance: Implications for financing preconception health.
        Women’s Health Issues. 2008; 18: S26-S35
        • Sakala C.
        U.S. health care reform legislation offers major new gains to childbearing women and newborns.
        Birth. 2010; 37: 337-340
        • Sommers B.D.
        • Rosenbaum S.
        Issues in health reform: How changes in eligibility may move millions back and forth between Medicaid and insurance exchanges.
        Health Affairs. 2011; 30: 228-236
        • U.S. Department of Health and Human Services (DHHS)
        Healthy people 2020 topics and objectives: Maternal, infant and child health.
        Office of Disease Prevention and Health Promotion, Washington, DC2010 (Available:) (Accessed June 30, 2011)
        • U.S. Centers for Disease Control and Prevention (CDC)
        Recommendations to improve preconception health and health care—United States: A report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care.
        Author, Atlanta2006 (Agency for Toxic Substances and Disease Registry (ATSDR). Available:) (Accessed June 30, 2011)
        • Wise P.H.
        Transforming preconceptional, prenatal, and interconceptional care into a comprehensive commitment to women’s health.
        Women’s Health Issues. 2008; 18: S13-S18

      Biography

      Katy Kozhimannil is Assistant Professor in the Division of Health Policy and Management at the University of Minnesota. She is a health policy analyst with expertise in studies of health care delivery, quality, and outcomes during the perinatal period.
      Jean Abraham is Assistant Professor in the Division of Health Policy and Management, University of Minnesota. She is a health economist who conducts research on access and cost of employer-based health insurance for workers and families.
      Beth Virnig is Professor in the Division of Health Policy and Management and Associate Dean for Research at the University of Minnesota’s School of Public Health. She is an epidemiologist and health services researcher who specializes in studies of health care utilization.