“Medicaid Expansion Associated With Some Improvements in Perinatal Mental Health” with Claire Margerison, Robert Kaestner, Sidra Goldman-Mellor, and Danielle Gartner. Health Affairs, (link). 

Abstract

Poor perinatal mental health is a common pregnancy-related morbidity with potentially serious impacts that extend beyond the individual to their families. A possible contributing factor to poor perinatal mental health is discontinuity in health insurance coveragem which is particularly important among low-income individuals. We examined impacts of Medicaid expansion on pre-pregnancy depression screening and self-reported depression and postpartum depressive symptoms and wellbeing among low-income individuals giving birth. Medicaid expansion was associated with a 16% decline in self-reported pre-pregnancy depression but was not associated with postpartum depressive symptoms or wellbeing. Associations between Medicaid expansion and pre-pregnancy mental health measures increased with time since expansion. Expanding health insurance to low-income individuals prior to pregnancy may improve perinatal mental health.

"Postpartum Medicaid Eligibility Expansions and Postpartum Health Measures" with Claire Margerison ( Population Health Management)  (link).

Abstract

Maternal mortality and morbidity in the US are high compared to similar countries, and racial disparities exist, with many of these events occurring in the later postpartum period. Proposed federal and recently enacted state policy interventions extend pregnancy Medicaid from covering 60 days to a full year postpartum. We estimate the association between maintaining Medicaid eligibility in the later postpartum period (relative to only having pregnancy Medicaid eligibility) with postpartum checkup attendance and depressive symptoms using regression analysis, overall and stratified by race/ethnicity. People with postpartum Medicaid eligibility were 1.0-1.4% more likely to attend a postpartum checkup relative to those with only pregnancy Medicaid eligibility overall, primarily driven by a 3.8-4.0% higher likelihood among Hispanic postpartum people. Conversely, postpartum Medicaid is associated with a 2.2-2.3% lower likelihood of postpartum checkup attendance for Black postpartum people. Postpartum eligibility is also associated with a 9.7-11.6% lower likelihood of self-reported depressive symptoms compared to only pregnancy Medicaid eligibility for white postpartum people only. Postpartum Medicaid eligibility is associated with some improvements in maternal healthcare utilization and mental health, but differences by race and ethnicity imply that inequitable systems and structures that cannot be overcome by insurance alone may also play an important role in postpartum health. 

"Impacts of the 2021 Child Tax Credit Advance Payments on Low Birth Weight in the United States" with Claire Margerison, Tim Bruckner, Ralph Catalano, Yasamean Zamani-Hanks and Tim Michling (JAMA Network Open) (link).

Abstract 

Importance: Infants and pregnant people in the US fare worse on almost all health measures compared with those in peer nations. Families in the US are more likely to live in poverty and have a less generous social safety net, which has generated debate over the contribution of economic conditions to this disparity. Objective  To assess the association between temporary increases in income during pregnancy through the 2021 expanded Child Tax Credit (CTC) and birth outcomes.Design, Setting, and Participants  This cross-sectional study applied a comparison-population, interrupted time series design to data from US birth certificates (January 1, 2014, through December 31, 2021) to test whether the log odds of low birth weight (LBW) among monthly cohorts of births exposed to the CTC would coincide with a decreased incidence of LBW. All singleton live births to US residents aged 15 to 49 years with available data were included.Exposure  Monthly birth cohorts exposed to the CTC were defined as those born to parous people during the CTC advance payment period from July through December 2021. Main Outcomes and Measures  The main outcome was the natural logarithm of the odds of LBW (<2500 g) among monthly birth cohorts. Results  Among included births (n = 28 866 466), 61.2% were to parous people, the majority were to people aged 20 to 39 years (91.7%), and 6.5% were born LBW. The odds of LBW increased above expected values in 5 of the 6 months of the CTC payments (range of increases, 3.3%-5.4% across the 5 months). The outlier-adjusted odds of LBW increased, on average, by 4.2% (95% CI, 2.7%-5.7%) among the monthly birth cohorts exposed to the CTC. Conclusions and Relevance  This study found that the odds of LBW among birth cohorts exposed to the CTC increased above expected values in 5 of the 6 months of the CTC advance payments. Additional research is needed to evaluate rival explanations for this increase in LBW among births exposed to the CTC payments.

“Did the Affordable Care Act promote Racial Equity in Pregnancy-Related Health?: A scoping review” with Colleen MacCallum-Bridges, Claire Margerison, Danielle Gartner, and Yasamean Zamani-Hanks. (Population Health Management) (link)

Abstract 

In the United States, there are profound and persistent racial and ethnic disparities in pregnancy-related health, emphasizing the need to promote racial health equity through public policy. There is evidence that the Affordable Care Act (ACA) increased health insurance coverage, access to health care, and health care utilization, and may have affected some pregnancy-related health outcomes (eg, preterm delivery). It is unclear, however, whether these impacts on pregnancy-related outcomes were equitably distributed across race and ethnicity. Thus, the objective of this study was to fill that gap by summarizing the peer-reviewed evidence regarding the impact of the ACA on racial and ethnic disparities in pregnancy-related health outcomes. The authors conducted a scoping review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR), using broad search terms to identify relevant peer-reviewed literature in PubMed, Web of Science, and EconLit. The authors identified and reviewed n = 21 studies and found that the current literature suggests that the ACA and its components were differentially associated with contraception-related and fertility-related outcomes by race/ethnicity. Literature regarding pregnancy health, birth outcomes, and postpartum health, however, was sparse and mixed, making it difficult to draw conclusions regarding the impact on racial/ethnic disparities in these outcomes. To inform future health policy that reduces racial disparities, additional work is needed to clarify the impacts of contemporary health policy, like the ACA, on racial disparities in pregnancy health, birth outcomes, and postpartum health. 

“Prepregnancy Health Care Engagement Among American Indian and Alaska Native People Before and After the Affordable Care Act” with Danielle Gartner, Heather Howard-Bobiwash, and Claire Margerison (Health Equity) (link)

Abstract

Background: Despite including several provisions focused on American Indian and Alaska Native (AI/AN) people, few studies look at the Affordable Care Act (ACA)'s potential impact among AI/AN birth givers, a group that experiences a disproportionate burden of adverse pregnancy outcomes. While ACA repeal conversations are ongoing, our objective was to examine changes, and equity in changes, in health care interactions before and after the ACA between AI/AN birth givers and white birth givers.

Materials and Methods: We used the 2009–2015 data from the Pregnancy Risk Assessment Monitoring System, a state-level representative sample of individuals with live births. We included those identifying as AI/AN people or white people to estimate change over time in five health measures. We used adjusted linear probability regression models to compare prepregnancy recall periods before, during, and after the implementation of the ACA with the period just before implementation.

Results: Among AI/AN birth givers, prepregnancy Medicaid coverage, multivitamin/prenatal use, and teeth cleaning increased by 10 percentage points (ppts), 5 ppts, and 9 ppts, respectively, and were larger than increases experienced by white birth givers (5, 3, and 2–4 ppts, respectively). Increases in preventive health care screening (12–18 ppts) and provider conversation (8–10 ppts) were similar for AI/AN birth givers and white birth givers.

Discussion: While some ACA-associated increases in health care coverage and care were quantitatively larger among AI/AN birth givers compared with white birth givers, the existence of pre-ACA disparities suggests that the ACA may have reduced, but may not have eliminated, health inequities between AI/AN birth givers and white birth givers.

“Impact of Medicaid Policies on Pre-pregnancy Preventive Dental Care” with Nazeeba Siddika, and Claire Margerison (Maternal and Child Health Journal) (link)

Abstract

Background: Dental care before pregnancy is critical for preventing poor oral health, which is associated with adverse pregnancy outcomes. People with low incomes, however, may face insurance-related barriers to obtaining dental care. Medicaid expansion under the Affordable Care Act increased access to dental care utilization among adults with low incomes. However, little is known about the impact of Medicaid policies on pre-pregnancy dental care utilization.Objective: To evaluate the impacts on pre-pregnancy dental care utilization of two aspects of Medicaid policy: (1) state level of Medicaid dental coverage and (2) Medicaid expansion overall and by state level of dental coverage. Methods: We used data from Pregnancy Risk Assessment Monitoring System (PRAMS) data phases 7 (2012–15) and 8 (2016–18). To examine the association between state level of dental coverage beyond emergency services (i.e., extensive vs. limited) and pre-pregnancy dental care utilization, we conducted an adjusted logistic regression analysis. To evaluate the impact of Medicaid expansion on pre-pregnancy dental care utilization, we conducted a quasi-experimental event study design, which estimates the percentage point difference in the outcome between expansion and non-expansion states at each time period compared to the period just prior to Medicaid expansion. Results: We found a significant 13% (adjusted odds ratio (OR) = 1.13; 95% CI: 1.05, 1.22) higher odds of pre-pregnancy dental care utilization among the birthing people residing in states that provided extensive dental coverage compared to those in states that provided limited dental coverage. However, Medicaid expansion under the ACA was not associated with pre-pregnancy dental care utilization overall or among either states with extensive or limited Medicaid dental coverage.

“Intertemporal Substitution in Response to Non-Linear Health Insurance Contracts” (email for latest draft)  

Abstract

Health insurance contracts with high annual deductibles have become increasingly popular in the U.S. This feature of insurance contracts allows consumers to substitute healthcare in one period for healthcare in another period by, for example, increasing consumption in the year the annual deductible was met and decreasing future consumption. I obtain an estimate of the causal effect of meeting the deductible on healthcare consumption in the following year. I exploit variation in the timing of an injury that generates significant healthcare expenses and a regression discontinuity design to identify the effect of meeting the deductible. Data for the analysis are from the Marketscan database of medical claims on privately insured individuals at large firms. Estimates indicate that there is intertemporal substitution in healthcare consumption. Reaching the coinsurance arm in one year leads to $13,263 less healthcare consumed, $788 less paid out of pocket, and 7.4 fewer care dates in the following year. For those induced to consume more healthcare by reaching the coinsurance arm of their plan, I find that for every dollar of discretionary healthcare consumed in the year the coinsurance arm is reached, roughly $0.56 less is consumed in the following year.

"Did Cash Transfers from the 2021 Child Tax Credit Expansion Improve Maternal and Infant Health? A Policy Brief" with Elizabeth Vickers, Yasamean Zamani-Hanks, and Claire Margerison (link)