America has an alarmingly high rate of infant mortality compared to other high-income countries. But the odds of death are particularly frightening for African Americans: Compared to white babies, black babies are more than twice as likely to die in infancy.
A new study points to a possible solution to this racial health gap: Make sure women have access to health insurance.
The paper, newly published in JAMA, focused on two birth outcomes — prematurity and low birth weight — which account for about 36 percent of all infant deaths. The researchers looked at how those outcomes changed after Medicaid expansion, comparing 17 states that didn’t expand Medicaid to 18 states and the District of Columbia that did in the years 2011 to 2016. (Today, 37 states have adopted Medicaid expansion.)
What they found was striking: The rates of prematurity and low infant birth-weight among black babies declined in the expansion states — where more women had access to medical care before, during, and after their pregnancies — while holding steady in non-expansion states.
“The largest contributor to infant health is maternal health,” said lead study author Clare Brown, a health policy instructor at the University of Arkansas for Medical Sciences. When moms go into pregnancy with unmanaged medical conditions — such as high blood pressure or diabetes — the odds of health complications for their babies increase. So if a woman can get medical care before her pregnancy, “to be healthier herself,” Brown added, “her infant may also be healthier.”
Researchers have repeatedly shown how access to Medicaid is linked to improved outcomes, including in HIV, depression, and diabetes, and in overall well-being. But this new study sheds light on an unexpected — and indirect — potential benefit of broadened healthcare access: It may be helping the most vulnerable babies in this country survive.
Why Medicaid expansion could indirectly affect infant health
Before we get into the details of the study, some context: There is a persistent, and disturbing, racial gap between the health outcomes of black and white babies (and their moms too). The mortality rate for black infants is 11.4 per 1,000, compared to only 4.9 for white babies, according to the latest data from the Centers for Disease Control and Prevention.
Black babies are also four times more likely to die from common birth complications linked to prematurity and low birth weight. The Affordable Care Act of 2010 wasn’t designed to directly address that disparity, but the new study suggests it might have anyway.
To understand how Medicaid expansion affected moms and babies in this country, we need to understand what access for low-income Americans looked like before Obamacare.
Prior to the ACA, in most states, only children and parents, pregnant women, or the disabled were eligible for Medicaid coverage, the government health insurance program for low-income Americans. In practice, this meant low-income pregnant women (who weren’t already parents or disabled) could go into a pregnancy without having seen a doctor for years. What’s more, across the US, hundreds of thousands of women lose their coverage just 60 days after giving birth. (These gaps in coverage are the focus of a reporting project from ProPublica and Vox.)
One of the centerpieces of the ACA was that it offered states federal funding to extend access to Medicaid to all low-income people, regardless of whether they were pregnant, already parents, or disabled. So in “expansion states” — or states that accepted the federal funding — anyone whose family income fell below 138 percent of the federal poverty level (about $15,000 for an individual) became eligible for Medicaid.
Brown and her co-authors hypothesized that this expanded access would mean more women suddenly had continuity of health care — before, during, and after pregnancies. “[And] if women had continual insurance, they’d be healthier themselves, and that would result in healthier babies.”
States that expanded Medicaid saw their rates of premature birth and low birth weight in black babies decline
So the researchers gathered data from the National Center for Health Statistics Birth Data Files for 2011 to 2016 to compare how two key infant health outcomes — preterm birth and low birth weight — differed in expansion versus non-expansion states before and after Medicaid expansion.
They also compared black and white infant outcomes, as well as Hispanic and white infant health outcomes.
Because black Americans had larger gains in health insurance following the Affordable Care Act compared to white Americans, and black infants have higher rates of adverse outcomes, Brown and her colleagues expected the biggest health benefits would turn up in black babies. And that’s exactly what they uncovered.
Overall, there were no statistically significant differences in infant health outcomes in expansion versus non-expansion states. But when outcomes of people of different races were examined separately, they showed African American babies had significant improvements in their health.
For low-birth weight among black babies, there was a decline of 4.5 percent in expansion states and an increase of 1.9 percent in non-expansion states between 2011 and 2016. For pre-term birth, there was another decline of 6 percent among black infants in expansion states and a 0.4 percent decline in non-expansion states. The health improvements in expansion states were even greater among the subset of Medicaid births to women who had at most a high school degree.
“We think what’s happening is not that non-expansion states are getting worse [when it comes to infant health outcomes] but that expansion states are breaking away from that trend,” Brown said.
While the study results don’t justify Medicaid expansion in and of itself, “it [highlights] one of more factors that contribute to the overall benefits of Medicaid expansion,” said J. Mick Tilford, a study author and health policy professor at the University of Arkansas for Medical Sciences. “Our study clearly shows [expansion] benefitted the groups that were most vulnerable.”
Right now, access to health care in America is becoming more uncertain for many families. For the first time in years, the uninsured rate rose in 2018 — with most of the losses occurring among low-income Americans, including those on Medicaid. Several states have also been trying to curtail access to Medicaid by introducing work requirements.
But as the authors of a commentary write, “Medicaid expansion may be helping to reduce racial disparities in one of the most important health indicators of a society — birth outcomes related to infant mortality.” By curtailing healthcare access, we may see those gains shrink away.
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ProPublica’s Nina Martin and I are teaming up for a reporting project about the gaps in health care insurance that women experience during and after pregnancy.
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