Reducing Racial and Ethnic Disparities in Maternal Health through Policy Interventions

The long-term goal of the proposed research project is to improve the health of minoritized racial and ethnic birthing people by reducing racial and ethnic disparities in severe maternal morbidity and maternal mortality. Specifically, the proposed research project will assess the effectiveness of 3 significant health insurance expansion policies in reducing racial and ethnic disparities in severe maternal morbidity (SMM): 1) the 2010 Dependent Coverage Provision under the Patient Protection and Affordable Care Act (ACA), requiring private health insurers to allow young adults to remain on their parent’s plan until their 26th birthday; 2) the 2014 ACA Medicaid expansion, giving states the option to expand Medicaid coverage to non- elderly adults with incomes up to 138% of the Federal Poverty Level; and 3) the Maintenance of Effort of the 2020 Families First Coronavirus Response Act (FFCRA) temporarily maintaining Medicaid coverage beyond 60-days postpartum as long the COVID-19 Public Health Emergency is in place. Minoritized racial and ethnic birthing people are three times more likely than non-Hispanic White people to experience SMM during childbirth and the postpartum. Addressing racial and ethnic disparities in SMM is recognized as an urgent public health priority. SMM refers to unintended serious complications of labor and delivery and is associated with substantially increased risk of maternal death. Providing continuous health insurance coverage through health policies, from preconception to 1-year postpartum, is a suggested intervention to mitigate these disparities. Up to 80% of minoritized racial and ethnic birthing people do not have such continuous coverage. However, evidence linking health insurance policy changes to reduced racial and ethnic disparities in SMM is scant. The 2010 ACA Dependent Coverage Provision, the 2014 ACA Medicaid expansion, and the 2020 FFCRA Maintenance of Effort present three natural experiments for assessing the effectiveness of expanding health insurance coverage in reducing racial and ethnic disparities in SMM. The proposed project will test a series of hypotheses related to the specific aims, including: 1) Expanded access to private health insurance for people under age 26 is associated with reduced racial and ethnic disparities in SMM; 2) Expanded Medicaid coverage for low-income people is associated with reduced racial and ethnic disparities in SMM, and 3) Extending Medicaid coverage for low-income people from 60-day to 1- year postpartum is associated with reduced racial and ethnic disparities in postpartum SMM. National and state data from the Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, will be analyzed using robust quasi-experimental approaches such as the difference-in-difference-in-differences. Results of this project will help close important gaps in health disparities research and provide rigorous evidence to inform policy interventions to reduce racial and ethnic health disparities among birthing people. It aligns with the aims of the IMPROVE initiative of the National Institutes of Health.