The Effect of Medicaid Expansion on Family Planning Outcomes for Low-Income Women Open Access

Abstract

A women’s ability to choose if and when she wants to become pregnant has a direct impact on her health and well-being [1]. Currently the US trails behind other highly economically developed countries in terms of maternal health. Ensuring women have the resources and knowledge to have reproductive autonomy will help ensure that women and children have the best opportunity to continue and begin healthy lives. 

The 2010 Patient Protection and Affordable Care Act (ACA) established many health care reforms in order to expand access to health insurance, protect patients, and reduce costs. A mechanism to increase access to health insurance was the expansion of Medicaid eligibility for low-income adults, especially low-income reproductive aged women, however, many states have still not adopted expansions. While there has been research that examines Medicaid expansion on access to pre-pregnancy insurance as well as studies that examined elements of the ACA on family planning outcomes there has yet to be a study that examines Medicaid expansion on a variety family planning outcomes for low-income women. The purpose of this investigation is to examine the effects of the ACA’s Medicaid expansion on family planning outcomes, measured by the proportion of unintended pregnancies, postpartum contraception use, and postpartum Medicaid coverage. This study utilized Pregnancy Risk Assessment Monitoring System 2011-2017 data and a difference in difference logistic regression analysis approach to test the effect of Medicaid expansion on the proportion of unintended pregnancies, postpartum contraception use, and postpartum Medicaid coverage for low-income reproductive aged women. Low-income women in Medicaid expansion states were 9 percentage points more likely to have postpartum Medicaid coverage post expansion than non-expansion states, however there was no effect found on unintended pregnancy or postpartum contraception use, which remained at 47% and 80% respectively. 

While the general analysis did not find significant effects’ beyond Medicaid coverage postpartum, the sensitivity analysis’s conducted revealed additional findings. By adhering to a more strict definition of expansion vs. non-expansion states, the results found previously were strengthen such that there was a 16 percentage point increase in likelihood that low-income women in expansion states would be more likely to have Medicaid coverage postpartum (from 42.8% to 58.9%). An additional sensitivity analysis restricted women to 100% FPL and utilized the strict definition of expansion vs. non-expansion found that the likelihood of unintended pregnancies decreased by 8 percentage points (from approximately 53% to 45%) and postpartum Medicaid coverage increased by 15 percentage points (from approximately 46% to 61%). While an additional sensitivity analysis, which restricted to 100% FPL held the strict definition, and omitted those aged 18-19 found the same 15 percentage point increase in postpartum Medicaid coverage, and a 10 percentage point decrease in unintended pregnancies (from approximately 53% to 44%). 

These findings suggest that Medicaid expansion is an element in improving access to reproductive planning and maternal health postpartum but it is not sufficient. These findings also suggest the need to protect these eligibility expansions, especially in the face of political uncertainty when ACA repeal, work requirements, and block grants are being discussed. 

Table of Contents

1 INTRODUCTION ................................................................................................................................... 1 

2 BACKGROUND AND LITERATURE REVIEW ................................................................................... 4 

Family Planning and Effects of Insurance............................................................................ 4 

The Interaction of Medicaid, The ACA, Medicaid Expansion, and Family Planning ............................................................................................................................................ 4 

Women and Medicaid, a History ............................................................................................. 4 

Legacy of Family Planning Policy in Medicaid ................................................................... 4 

Introduction of ACA, Medicaid Expansion & Family Planning..................................... 5 

Expansion and Non-Expansion States, Systematic Differences .................................. 6 

Current Literature and Gaps .......................................................................................................... 7 

The effects of Medicaid Expansion on insurance coverage and access to care ..... 7 

The effects of ACA Mandate Provisions on Family Planning Outcomes .................. 9 

3 METHODOLOGY: CONCEPTUAL FRAMEWORK ................................................................... 13 

Focal Relationship ...................................................................................................................... 14 

Mediators ...................................................................................................................................... 15 

Contextual level confounders and their association with constructs in the focal relationship .................................................................................................................................. 16 

Individual level confounders and their association with constructs in the focal relationship .................................................................................................................................. 17 

TESTABLE HYPOTHESIS ......................................................................................................... 19 

DATA DESCRIPTION ................................................................................................................. 20 

CONSTRUCT MEASUREMENT ............................................................................................... 21 

ANALYTIC PLAN ......................................................................................................................... 25 

4. Results ................................................................................................................................................. 29 

Descriptive Statistics................................................................................................................. 29 

Descriptive Results .................................................................................................................... 31 

Data Analysis of Model A ......................................................................................................... 33 

Data Analysis of Model B (Sensitivity Analysis ............................................................... 33 

Results of Model A ..................................................................................................................... 33 

Sensitivity Analysis, Results of Model B ............................................................................ 37 

Sensitivity Analysis Model C, D, E, & F ............................................................................... 40 

5. Discussion .......................................................................................................................................... 42 3 

Key Findings ................................................................................................................................. 42 

Limitations and Strengths ....................................................................................................... 43 

Policy Implications .................................................................................................................... 45 

Future Challenges ...................................................................................................................... 47 

Conclusion ..................................................................................................................................... 47 

APPENDIX ............................................................................................................................................... 48 

Model B: Sensitivity Analysis Strict Definition Tables and Figures 5A to 5D ..... 48 

Model C: Sensitivity Analysis FPL<100% and Generous Definition Tables and Figures 6A to 6D ......................................................................................................................... 52 

Model D: Sensitivity Analysis FPL<100% and Strict Definition Tables and Figures 7A to 7D ......................................................................................................................... 57 

Table 6. Summary of Predicated Probability Estimates of Models ......................... 64 

About this Master's Thesis

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School	Rollins School of Public Health
Department	Health Policy and Management
Degree	M.S.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health
Keyword	Family Planning
Committee Chair / Thesis Advisor	Silke von Esenwein, PhD, Emory University Peter Joski, MSPH, Emory University Kathleen Adams, PhD, Emory University

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