Effect of Publicly Subsidized Health Insurance on the Birth Rate and Pregnancy-related Health

This presentation will evaluate how access to publicly subsidized health insurance prior to conception affects the U.S. birth rate, and for those who become pregnant, how such insurance affects maternal health behaviors and birth outcomes. Uninsurance for childbearing aged women presents two unique challenges: avoiding pregnancy and paying for pregnancy. Without insurance, women struggle to get access to the most effective forms of contraception. For women who became pregnant, the lowest income ones are eligible for Medicaid coverage for their pregnancies, but those with incomes higher than this threshold would likely have to pay for the pregnancy out of pocket. The Affordable Care Act (ACA) greatly expanded subsidized insurance options for childless adults. It removed Medicaid’s categorical eligibility requirements that enrollees are children, elderly, disables, parents, or pregnant by allowing states to choose to extend Medicaid coverage to all adults up to 138% FPL. Additionally, adults between 100 (138) and 400% FPL were eligible for subsidies to purchase non-group health insurance in non-expansion (expansion) states. The ACA also required maternity and newborn care to be covered by all plans and forbid differential treatment based on pre-existing conditions such as pregnancy. This array of changes to access and costs could influence women’s choices regarding pregnancy, prenatal care and other maternal health behaviors, and birth outcomes.

I use an imputed eligibility measure equal to the share of women eligible for subsidized health insurance by demographic bins, state, and conception month to test the effect of eligibility on the birthrate for childless women of childbearing age between 2010 and 2015. My results indicate that expanding Medicaid had no significant effect on the birth rate, but that non-Medicaid, subsidized health insurance plans increased the birth rate. The latter group saw substantial reductions in pregnancy-related expenses whereas the Medicaid expansion population experience no substantial change in the cost of pregnancy.

Having insurance prior to conception can improve women’s familiarity with the health care system, which could improve pregnancy related care. While pregnancy-conditional Medicaid beneficiaries may not realize they are eligible, a woman enrolled in Medicaid or a subsidized Marketplace plan prior to becoming pregnant knows she has insurance and is more likely to know where she can get an appointment. Prior familiarity with medical institutions reduces the emotional and time costs of scheduling a first prenatal care visit and should lead to earlier visits. Additionally, I look at how this insurance affects maternal health behaviors, such as smoking and maternal weight gain, and birth outcomes, such as the incidence of preterm and low birth weight infants.