Has Medicaid expansion, in the states in which the program has been expanded, led to mental health improvement among pregnant residents of those states? The evidence appears to indicate so. A team of researchers performed a data analysis that points to small improvements in several different areas, and reported their results in the October issue of Health Affairs.
In “Medicaid Expansion Associated With Some Improvements In Perinatal Mental Health,” Claire E. Margerison, Katlyn Hettinger, Robert Kastner, Sidra Goldman-Mellor, and Danielle Gartner open their article by writing that “Poor perinatal mental health is a common pregnancy-related morbidity with potentially serious impacts that extend beyond the individual to their family. A possible contributing factor to poor perinatal mental health is discontinuity in health insurance coverage, which is particularly important among low-income people. We examined impacts of Medicaid expansion on pre-pregnancy depression screening and self-reported depression and postpartum depressive symptoms and well-being among low-income people giving birth. Medicaid expansion was associated with a 16 percent decline in self-reported pre-pregnancy depression but was not associated with postpartum depressive symptoms or well-being. Associations between Medicaid expansion and pre-pregnancy mental health measures increased with time since expansion. Expanding health insurance coverage to low-income people before pregnancy may improve perinatal mental health.”
The researchers not that “Poor perinatal mental health is a common pregnancy-related morbidity, affecting between 13 percent and 25 percent of people who have recently given birth, with higher prevalence among low-income birthing people. Mental health is central to the well-being of the birthing person, their children, and their family, and if left untreated,” they note, “Poor perinatal mental health may lead to detrimental and cascading sequelae including mortality during pregnancy and the first year postpartum.”
What’s more, they note, “Having health insurance before, during, and after pregnancy is plausibly an important determinant of perinatal mental health because insurance increases one’s ability to obtain timely and effective care, However, many pregnant and birthing people, particularly those with low incomes, do not have health insurance or experience changes or lapses in health insurance coverage before, during, or after pregnancy.”
And even though, since April 1990, all fifty states have been required to provide Medicaid to pregnant people with household incomes up to 133 percent of the federal poverty level, many states are using cutoffs at far higher percentages of the federal poverty level (for example, Iowa now uses a cutoff of 380 of the federal poverty level). What’s more, as the researchers note, “[I]n most states, before the Affordable Care Act (ACA), there were no income eligibility thresholds for non-pregnant, non-disabled adults with no dependent children. This remains the case in states that did not expand Medicaid under the ACA, meaning that low-income people in these states may lack insurance before pregnancy and thus access to preconception care. Moreover, birthing people who qualify for Medicaid during pregnancy typically lose pregnancy-related Medicaid coverage after sixty days postpartum and must requalify under parental income guidelines.”
Scanning that policy landscape, the researchers “used a difference-in-differences study design, which estimates the change in outcomes post-Medicaid expansion compared with pre-expansion among pregnant people in expansion states compared with those in non-expansion states.”
And what did they find? In a population that was “49 percent non-Hispanic white, 18 percent non-Hispanic Black, 24 percent Hispanic, and less than 10 percent each non-Hispanic Native American, Native Alaskan, or Native Hawaiian; Asian; or mixed other, based on self-reported race and ethnicity,” that “About 27 percent of PRAMS [Pregnancy Risk Assessment Monitoring System] respondents reported being screened for depression before pregnancy, 16 percent reported having depression before pregnancy, and 16 percent reported postpartum depressive symptoms. Before adjustment, Medicaid expansion was associated with increases in pre-pregnancy and postpartum Medicaid insurance, declines in pre-pregnancy self-reported depression, and increases in pre-pregnancy screening and postpartum well-being.”
Specifically, “Medicaid expansion was significantly associated with a 9.6-percentage-point (22 percent) increase in pre-pregnancy Medicaid coverage, a 2.5-percentage-point (16 percent) decrease in self-reported pre-pregnancy depression, and a non-significant increase of 2.3 percentage points (9 percent) in pre-pregnancy screening for depression. With increasing time (three to four years) since Medicaid, expansion, we found even larger associations between Medicaid expansion and pre-pregnancy depression (a 3.7-percentage-point decrease) and screening (a 4.4-percentage-point increase), although power declined with fewer observations in the smaller time increments. Medicaid expansion was not associated with substantial changes in postpartum depressive symptoms or well-being.”
As the article’s authors note, “Our finding that Medicaid expansion decreased pre-pregnancy self-reported depression and may have increased pre-pregnancy screening for depression suggests that low-income people gaining Medicaid insurance used more preventive healthcare before pregnancy than those not gaining Medicaid coverage, or that insurance coverage and increased preventive care improve some measures of mental health.” And, as a result of those findings, the authors conclude that “Expanding health insurance coverage to low-income people before pregnancy may improve perinatal mental health.”
Claire E. Margerison, Ph.D., is an associate professor in the Department of Epidemiology and Biostatistics at Michigan State University (East Lansing). Katlyn Hettinger is a graduate research assistant in the Department of Epidemiology and Biostatistics and a doctoral student in the Department of Economics at Michigan State University. Robert Kaestner, Ph.D., is a research professor in the Harris School of Public Policy at the University of Chicago. Sidra Goldman-Mellor, Ph.D., is an associate professor of public health at the University of California Merced. Danielle Gartner is a research associate in the Department of Epidemiology and Biostatistics at Michigan State University.
