The Association Between Postpartum Insurance Instability and Access to Postpartum Mental Health Services: Evidence From Colorado

Published:August 01, 2022DOI:



      The objective of this study was to assess the association between postpartum insurance instability and access to postpartum mental health services.


      We used 2018–2019 Colorado Health eMoms survey data, which sampled mothers from the 2018 birth certificate files at 3–6 months and 12–14 months postpartum. Respondents were classified as stably insured or unstably insured based on postpartum insurance status at each time point. We examined postpartum insurance patterns and used logistic regression to assess the association between postpartum insurance instability and mental health care access.


      Insurance changes primarily occurred by 3–6 months postpartum. Of respondents with public coverage at childbirth, 33.2% experienced postpartum insurance changes compared with 9.5% with private coverage (p < .001). Respondents who were younger, had incomes of less than $50,000, and were of Hispanic ethnicity were more likely to experience unstable postpartum insurance. Respondents who experienced postpartum insurance instability had a lower odds of reporting that they discussed mental health at a postpartum check-up (adjusted odds ratio, 0.4; 95% confidence interval, 0.2–0.7; p < .01) and received postpartum mental health services (adjusted odds ratio, 0.4; 95% confidence interval, 0.2–0.9; p < .05).


      The majority of postpartum insurance disruptions occurred among respondents with public coverage at childbirth and by 3–6 months postpartum. Respondents who experienced unstable coverage were more likely to have less access to postpartum mental health care. Policies that increase postpartum insurance stability, such as postpartum Medicaid extensions beyond 60 days, are needed to improve access to postpartum mental health services.
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        • Admon L.K.
        • Daw J.R.
        • Winkelman T.N.A.
        • Kozhimannil K.B.
        • Zivin K.
        • Heisler M.
        • Dalton V.K.
        Insurance coverage and perinatal health care use among low-income women in the US, 2015-2017.
        JAMA Network Open. 2021; 4: e2034549
        • Allen H.
        • Gordon S.H.
        • Lee D.
        • Bhanja A.
        • Sommers B.D.
        Comparison of utilization, costs, and quality of Medicaid vs subsidized private health insurance for low-income adults.
        JAMA Network Open. 2021; 4: e2032669
        • Baicker K.
        • Allen H.L.
        • Wright B.J.
        • Taubman S.L.
        • Finkelstein A.N.
        The effect of Medicaid on management of depression: Evidence from the Oregon Health Insurance Experiment: The effect of Medicaid on management of depression.
        Milbank Quarterly. 2018; 96: 29-56
        • Baicker K.
        • Taubman S.L.
        • Allen H.L.
        • Bernstein M.
        • Gruber J.H.
        • Newhouse J.P.
        • Finkelstein A.N.
        The Oregon Experiment—Effects of Medicaid on clinical outcomes.
        New England Journal of Medicine. 2013; 368: 1713-1722
        • Brooks T.
        • Roygardner T.
        • Artiga S.
        Medicaid and CHIP eligibility, enrollment, and cost sharing policies as of January 2019: Findings from a 50-state survey.
        Kaiser Family Foundation, 2019 (Available:) (Accessed: April 2, 2022)
        • Building U.S. Capacity to Review and Prevent Maternal Deaths
        Report from nine maternal mortality review committees.
        (Available:) (Accessed: April 2, 2022)
        • Centers for Disease Control and Prevention (CDC)
        PRAMS methodology.
        (Available:) (Accessed: May 31, 2022)
        • Chen A.
        Pregnancy-related Medicaid and minimum essential coverage. National Health Law Program.
        (Available:) (Accessed: April 3, 2022)
        • Colorado Department of Public Health and Environment
        Health eMoms 2018 Survey data.
        (Available:) (Accessed: December 8, 2021)
        • D’Angelo D.V.
        • Le B.
        • O’Neil M.E.
        • Williams L.
        • Ahluwalia I.B.
        • Harrison L.L.
        • Grigorescu V.
        Patterns of health insurance coverage around the time of pregnancy among women with live-born infants—Pregnancy Risk Assessment Monitoring System, 29 States, 2009.
        Morbidity and Mortality Weekly Report. Surveillance Summaries. 2015; 64: 1-19
        • Daw J.R.
        • Hatfield L.A.
        • Swartz K.
        • Sommers B.D.
        Women in the united states experience high rates of coverage “churn” in months before and after childbirth.
        Health Affairs. 2017; 36: 598-606
        • Ela E.J.
        • Vizcarra E.
        • Thaxton L.
        • White K.
        Insurance churn and postpartum health among Texas women with births covered by Medicaid/CHIP.
        Women’s Health Issues. 2021; 32: 92-102
        • Fairbrother N.
        • Janssen P.
        • Antony M.M.
        • Tucker E.
        • Young A.H.
        Perinatal anxiety disorder prevalence and incidence.
        Journal of Affective Disorders. 2016; 200: 148-155
        • Gordon S.H.
        • Sommers B.D.
        • Wilson I.B.
        • Trivedi A.N.
        Effects of Medicaid expansion on postpartum coverage and outpatient utilization. Comparing Colorado, which expanded Medicaid, and Utah, which did not.
        Health Affairs. 2020; 39: 77-84
        • Ji X.
        • Wilk A.S.
        • Druss B.G.
        • Lally C.
        • Cummings J.R.
        Discontinuity of Medicaid coverage: Impact on cost and utilization among adult Medicaid beneficiaries with major depression.
        Medical Care. 2017; 55: 735-743
        • Kaiser Family Foundation
        Medicaid postpartum coverage extension tracker.
        (Available:) (Accessed: May 31, 2022)
        • Kallem S.
        • Matone M.
        • Boyd R.C.
        • Guevara J.P.
        Mothers’ mental health care use after screening for postpartum depression at well-child visits.
        Academic Pediatrics. 2019; 19: 652-658
        • Ko J.Y.
        • Farr S.L.
        • Dietz P.M.
        • Robbins C.L.
        Depression and treatment among U.S. pregnant and nonpregnant women of reproductive age, 2005-2009.
        Journal of Women’s Health (2002). 2012; 21: 830-836
        • Lavarreda S.A.
        • Gatchell M.
        • Ponce N.
        • Brown E.R.
        • Chia Y.J.
        Switching health insurance and its effects on access to physician services.
        Medical Care. 2008; 46: 1055-1063
        • Metz T.D.
        • Rovner P.
        • Hoffman M.C.
        • Allshouse A.A.
        • Beckwith K.M.
        • Binswanger I.A.
        Maternal deaths from suicide and overdose in Colorado, 2004–2012.
        Obstetrics & Gynecology. 2016; 128: 1233-1240
        • National Academy for State Health Policy
        View each state’s efforts to extend Medicaid coverage to postpartum women.
        (Available:) (Accessed: May 31, 2022)
        • Shorey S.
        • Chee C.Y.I.
        • Ng E.D.
        • Chan Y.H.
        • Tam W.W.S.
        • Chong Y.S.
        Prevalence and incidence of postpartum depression among healthy mothers: A systematic review and meta-analysis.
        Journal of Psychiatric Research. 2018; 104: 235-248
        • Sommers B.D.
        • Gourevitch R.
        • Maylone B.
        • Blendon R.J.
        • Epstein A.M.
        Insurance churning rates for low-income adults under health reform: Lower than expected but still harmful for many.
        Health Affairs. 2016; 35: 1816-1824
        • Wright B.J.
        • Carlson M.J.
        • Allen H.
        • Holmgren A.L.
        • Rustvold D.L.
        Raising premiums and other costs for Oregon health plan enrollees drove many to drop out.
        Health Affairs. 2010; 29: 2311-2316
        • Zhu J.M.
        • Zhang Y.
        • Polsky D.
        Networks in ACA Marketplaces are narrower for mental health care than for primary care.
        Health Affairs. 2017; 36: 1624-1631


      Erica L. Eliason, PhD, MPH, is a postdoctoral research fellow at Brown University School of Public Health. Her research evaluates the effects of health insurance on maternal, child, and reproductive health, with a particular focus on Medicaid policies.


      Sarah H. Gordon, PhD, MS, is an assistant professor in the Department of Health Law, Policy, and Management at the Boston University School of Public Health. She studies Medicaid policy, maternal health, and health insurance.