Medicaid Expansion Means Better Postpartum Coverage, Utilization

January 20, 2020 - Medicaid expansion may influence postpartum coverage stability and outpatient utilization based on results from Colorado and Utah’s Medicaid programs, a recent Health Affairs study found.

Using longitudinal administrative data from Utah and claims data from Colorado from between 2013 and 2015 – the period during which the ACA allowed Medicaid expansion, the researchers found better postpartum coverage for Colorado mothers.

The researchers found that Utah—which did not expand Medicaid—experienced a decline in postpartum coverage after this time period, while Colorado—which did expand Medicaid coverage—saw its coverage for women in the postpartum phase remain stable.

 “These findings have implications for other states considering expansion and also represent an important step toward reducing rates of maternal morbidity and mortality in the United States,” the researchers explained.

Women in Colorado had 1.4 months of postpartum coverage for those suffering severe maternal morbidity and 0.9 months of postpartum coverage otherwise. 

The expansion state saw a 17.3 percent increase in outpatient utilization as compared to Colorado’s baseline rate. Among women with severe maternal morbidity, the rate was even higher, resulting in 1.3 Medicaid-financed postpartum outpatient visits compared to the average 0.5 visits for women who did not have severe maternal morbidity. 

The researchers found that Colorado women were more likely than Utah women to utilize Medicaid-financed outpatient care during the postpartum period. In particular, Colorado utilization was high in the crucial 31 to 90-day period after birth. This is the timeframe in which new mothers on Medicaid are most likely to lose their healthcare coverage.

The researchers noted that the number of commercial payer-financed visits was higher in Utah than in Colorado. These commercial visits resulted in slightly slimmer expansion effects. However, the point estimate went from 0.52 for Medicaid-financed visits to 0.49 for all visits.

The benefits of expansion seemed to be most evident in high-risk scenarios. In the expansion state, there was higher use of Medicaid among women who suffered severe maternal morbidity. Women in Colorado who suffered high-risk complications like this were 50 percent more likely to visit an outpatient facility than Utah women.

In addition to utilization, the study revealed coverage differences between the two states that may have been caused by and served to perpetuate issues related to Medicaid expansion. 

The researchers postulated that the need to transition from Medicaid to ACA coverage during the postpartum period might have led to coverage declines in Utah. 

These declines did not seem to stem from Utah mothers shifting from Medicaid to commercial insurance. In Colorado, the postpartum population increased in Medicaid-financed outpatient settings, indicating that women remained in the Medicaid system. 

In Utah, however, there was no significant increase in commercial postpartum outpatient utilization to indicate that women were switching to commercial plans.

“One possible reason we did not observe substitution in postpartum outpatient care via Utah’s private market is that mothers with incomes below 100 percent of poverty are ineligible for subsidized Marketplace coverage,” the researchers explained. “Even if women are eligible for an alternative source of postpartum health insurance, transitions from Medicaid to other commercial coverage may still disrupt continuity of care.”

The changes in coverage and utilization over the course of the study were not significant. 

Researchers suggested this may be due to an inability to identify women who qualified for pre-ACA coverage in Colorado. The insignificance of the changes in each state may indicate that Colorado already had higher coverage and utilization than Utah before its expansion. It could also be affected by access to care obstacles in both Colorado and Utah related to their rural healthcare.

Colorado’s Medicaid expansion included infrastructure and outreach funding, leading to better education of mothers about how to manage their postpartum insurance through Medicaid. Utah may achieve better results if it used Medicaid expansion to increase its postpartum population’s awareness.

They also found that Colorado mothers only experienced a slight income increase. This may indicate that Utah could receive similar results as Colorado through Medicaid expansion.

Colorado is currently considering further changes to its healthcare program through a proposed public option. The proposal aims to decrease premiums and out-of-pocket healthcare spending with a federal waiver.

The expansion state has also been implementing a three-tiered reinsurance program, which is expected to cut premiums by 16 percent.

Meanwhile, CMS has approved a plan for Utah to implement work requirements. The state has not yet implemented its proposed plan.