Impacts of the Affordable Care Act's Medicaid Expansion on Women of Reproductive Age: Differences by Parental Status and State Policies

Published:December 20, 2017DOI:



      We use data from the Behavioral Risk Factor Surveillance System (BRFSS) from 2012 to 2015 to estimate the effects of the Affordable Care Act's (ACA) Medicaid expansions on insurance coverage and access to care for low-income women of reproductive age (19–44).


      We use two-way fixed effects difference-in-differences models to estimate the effects of Medicaid expansions on low-income (<100% of the Federal Poverty Level) women of reproductive age. Additional models are stratified to estimate effects based on women's parental status, pre-ACA state Medicaid eligibility levels, and the presence of a state Medicaid family planning waiver.


      ACA Medicaid expansions decreased uninsurance among low-income women of reproductive age by 13.2 percentage points. This decrease was driven by a decrease of 27.4 percentage points for women without dependent children, who also experienced a decrease in the likelihood of not having a personal doctor (13.3 percentage points). We find a 3.8-percentage point reduction in the likelihood of experiencing a cost barrier to care among all women, but no significant effects for other access measures or subgroups. When stratified by state policies, decreases in uninsurance were greater in states expanding from pre-ACA eligibility levels of less than 50% of Federal Poverty Level (19.4 percentage points) and in states without a Medicaid family planning waiver (17.6 percentage points).


      The ACA Medicaid expansion increased insurance coverage for low-income women of reproductive age, with the greatest effects for women without dependent children and women residing in states with relatively lower pre-ACA Medicaid eligibility levels or with no family planning waiver before the ACA.
      To read this article in full you will need to make a payment


      Subscribe to Women's Health Issues
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Adams E.K.
        • Johnston E.M.
        Insuring women in the United States before, during, and after pregnancies.
        American Journal of Public Health. 2016; 106: 585
        • Andersen R.
        • Aday L.A.
        Access to medical care in the US: Realized and potential.
        Medical Care. 1978; : 533-546
        • Antonisse L.
        • Garfield R.
        • Rudowitz R.
        • Artiga S.
        The effects of Medicaid expansion under the ACA: Findings from a literature review.
        The Kaiser Family Foundation, Washington, DC2016 (Available:) (Accessed: March 25, 2017)
        • Artiga S.
        • Rudowitz R.
        • McGinn-Shapiro M.
        Expanding Medicaid to low-income childless adults under health reform: Key lessons from state experiences.
        Kaiser Family Foundation, Washington, DC2010
        • 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
        • Bailey M.J.
        Fifty years of family planning: New evidence on the long-run effects of increasing access to contraception.
        National Bureau of Economic Research, 2013 (Available:) (Accessed: January 13, 2017)
        • Biermann J.
        • Dunlop A.L.
        • Brady C.
        • Dubin C.
        • Brann A.
        Promising practices in preconception care for women at risk for poor health and pregnancy outcomes.
        Maternal and Child Health Journal. 2006; 10: S21-28
        • Blewett L.A.
        • Johnson P.J.
        • Lee B.
        • Scal P.B.
        When a usual source of care and usual provider matter: Adult prevention and screening services.
        Journal of General Internal Medicine. 2008; 23: 1354
        • Courtemanche C.
        • Marton J.
        • Ukert B.
        • Yelowitz A.
        • Zapata D.
        Early impacts of the Affordable Care Act on health insurance coverage in Medicaid expansion and non-expansion states.
        Journal of Policy Analysis and Management. 2017; 36: 178-210
        • Currie J.
        • Gruber J.
        Saving Babies: The efficacy and cost of recent changes in the Medicaid eligibility of pregnant women.
        Journal of Political Economy. 1996; 104: 1263-1296
        • DeVoe J.E.
        • Fryer G.E.
        • Phillips R.
        • Green L.
        Receipt of preventive care among adults: Insurance status and usual source of care.
        American Journal of Public Health. 2003; 93: 786-791
        • Dubay L.
        • Joyce T.
        • Kaestner R.
        • Kenney G.M.
        Changes in prenatal care timing and low birth weight by race and socioeconomic status: Implications for the Medicaid expansions for pregnant women.
        Health Services Research. 2001; 36: 373-398
        • Finkelstein A.
        • Taubman S.
        • Wright B.
        • Bernstein M.
        • Gruber J.
        • Newhouse J.P.
        • Oregon Health Study Group
        The Oregon Health Insurance Experiment: Evidence from the first year.
        Quarterly Journal of Economics. 2012; 127: 1057-1106
        • 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
        • Jack B.W.
        • Culpepper L.
        Preconception care: Risk reduction and health promotion in preparation for pregnancy.
        Jama. 1990; 264: 1147-1149
        • Johnson K.M.
        • Applegate M.
        • Gee R.E.M.
        Improving Medicaid: Three decades of change to better serve women of childbearing age.
        Clinical Obstetrics & Gynecology. 2015; 58: 336-354
        • Johnson K.
        • Posner S.F.
        • Biermann J.
        • Codero J.F.
        • Atrash H.K.
        • Parker C.S.
        • Curtis M.G.
        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 (pp. 1–23.
        Centers for Disease Control and Prevention, Atlanta, GA2006 (Available:) (Accessed: August 1, 2016)
        • Kaiser Family Foundation
        Medicaid and CHIP income eligibility limits for pregnant women, 2003-2016.
        2016 (Available:) (Accessed: September 6, 2016)
        • Kaiser Family Foundation
        Current status of state Medicaid expansion decisions.
        2017 (Available:) (Accessed: May 17, 2015)
        • Lu M.C.
        • Halfon N.
        Racial and ethnic disparities in birth outcomes: A life-course perspective.
        Maternal and Child Health Journal. 2003; 7: 13-30
        • Lu M.C.
        • Kotelchuck M.
        • Culhane J.F.
        • Hobel C.J.
        • Klerman L.V.
        • Thorp J.M.
        Preconception care between pregnancies: The content of internatal care.
        Maternal and Child Health Journal. 2006; 10: 107-122
        • MACPAC
        March 2014 Report to the Congress on Medicaid and CHIP.
        2014 (Available:) (Accessed: August 9, 2016)
        • McCormick M.C.
        Prenatal care–Necessary but not sufficient.
        Health Services Research. 2001; 36: 399-403
        • McMorrow S.
        • Gates J.
        • Long S.
        • Kenney G.
        Affordable Care Act Medicaid expansion increased coverage, improved affordability of care, and reduced psychological distress for low-income parents.
        Health Affairs. 2017; 36: 808-818
        • Miller S.
        • Wherry L.R.
        Health and access to care during the first 2 years of the ACA Medicaid expansions.
        New England Journal of Medicine. 2017; 376: 947-956
        • Polsky D.
        • Candon M.
        • Saloner B.
        • Wissoker D.
        • Hempstead K.
        • Kenney G.M.
        • Rhodes K.
        Changes in primary care access between 2012 and 2016 for new patients with Medicaid and private coverage.
        JAMA Internal Medicine. 2017; 177: 588-590
        • Ross D.C.
        • Jarlenski M.
        • Artiga S.
        • Marks C.
        A foundation for health reform: Findings of an annual 50-state survey of eligibility rules, enrollment and renewal procedures and cost-sharing practices in Medicaid and CHIP for children and parents during 2009 (Kaiser Commission on Medicaid and the Uninsured No. 8028).
        Kaiser Family Foundation, Washington, DC2009 (Available:) (Accessed: May 7, 2017)
        • Sabik L.M.
        • Tarazi W.W.
        • Hochhalter S.
        • Dahman B.
        • Bradley C.J.
        Medicaid expansions and cervical cancer screening for low-income women.
        Health Services Research. 2017; (Available:) (Accessed: September 12, 2017)
        • Salganicoff A.
        • An J.
        Making the most of Medicaid.
        Women’s Health Issues. 2008; 18: S41-S46
        • Salganicoff A.
        • An J.
        Making the most of Medicaid: Promoting the health of women and infants with preconception care.
        Women’s Health Issues. 2008; 18: S41-S46
        • Shi L.
        • Nie X.
        • Wang T.-F.
        Type of usual source of care and access to care.
        Journal of Ambulatory Care Management. 2013; 36: 209-221
        • Simon K.
        • Soni A.
        • Cawley J.
        The impact of health insurance on preventive care and health behaviors: Evidence from the first two years of the ACA Medicaid expansions.
        Journal of Policy Analysis and Management. 2017; 36: 390-417
        • Sommers B.D.
        • Arntson E.
        • Kenney G.M.
        • Epstein A.M.
        Lessons from early Medicaid expansions under health reform: Interviews with Medicaid officials.
        Medicare & Medicaid Research Review. 2013; 3
        • Sommers B.D.
        • Baicker K.
        • Epstein A.M.
        Mortality and access to care among adults after state Medicaid expansions.
        New England Journal of Medicine. 2012; 367: 1025-1034
        • Sommers B.D.
        • Gunja M.Z.
        • Finegold K.
        • Musco T.
        Changes in self-reported insurance coverage, access to care, and health under the Affordable Care Act.
        JAMA. 2015; 314: 366
        • Sommers B.D.
        • Kenney G.M.
        • Epstein A.M.
        New evidence on the Affordable Care Act: Coverage impacts of early Medicaid expansions.
        Health Affairs. 2014; 33: 78-87
        • Sonfield A.
        • Frost J.J.
        • Gold R.B.
        Estimating the impact of expanding Medicaid eligibility for family planning services: 2011 update.
        Guttmacher Institute, New York2011 (Available:) (Accessed: January 12, 2017)
        • Sonfield A.
        • Hasstedt K.
        • Kavanaugh M.L.
        • Anderson R.
        The social and economic benefits of women’s ability to determine whether and when to have children.
        Guttmacher Institute, New York2013 (Available:) (Accessed: July 11, 2016)
        • Wherry L.R.
        • Miller S.
        Early coverage, access, utilization, and health effects associated with the Affordable Care Act Medicaid expansions: A quasi-experimental study.
        Annals of Internal Medicine. 2016; 164: 795-803


      Emily M. Johnston, PhD, is a Research Associate in the Health Policy Center at the Urban Institute. Her research focuses on access to health care, particularly the effects of state and federal policies on the health and well-being of vulnerable populations.


      Andrea E. Strahan, MPP, is a PhD student in the department of Health Policy and Management in the Rollins School of Public Health, Emory University. Her research interests focus on policies that affect access and care delivery for women and children.


      Peter Joski, MSPH, is a Senior Associate in the department of Health Policy and Management in the Rollins School of Public Health, Emory University, with a focus on data management and statistical analysis using SAS/Stata.


      Anne L. Dunlop, MD, MPH, Associate Professor, Emory University Nell Hodgson Woodruff School of Nursing, is a family and preventive medicine physician and maternal-child health researcher who conducts health services and epidemiologic research in women's preconception and interconception health care.


      E. Kathleen Adams, PhD, is Professor in the department of Health Policy and Management in the Rollins School of Public Health, Emory University. Her research is focused on the Medicaid program and other policies affecting access for low-income and vulnerable populations.