Racial and Ethnic Disparities in Perinatal Insurance Coverage

Jamie R Daw, Giselle E Kolenic, Vanessa K Dalton, Kara Zivin, Tyler Winkelman, Katy B Kozhimannil, Lindsay K Admon, Jamie R Daw, Giselle E Kolenic, Vanessa K Dalton, Kara Zivin, Tyler Winkelman, Katy B Kozhimannil, Lindsay K Admon

Abstract

Objective: To measure the association between race-ethnicity and insurance status at preconception, delivery, and postpartum and the frequency of insurance gaps and transitions (disruptions) across these time points.

Methods: We conducted a cross-sectional analysis of survey data from 107,921 women in 40 states participating in the Centers for Disease Control and Prevention's Pregnancy Risk Assessment and Monitoring System from 2015 to 2017. We calculated unadjusted estimates of insurance status at preconception, delivery, and postpartum and continuity across these time points for seven racial-ethnic categories (white non-Hispanic, black non-Hispanic, indigenous, Asian or Pacific Islander, Hispanic Spanish-speaking, Hispanic English-speaking, and mixed race or other). We also examined unadjusted estimates of uninsurance at each perinatal time period by state of residence. We calculated adjusted differences in the predicted probability of uninsurance at preconception, delivery, and postpartum using logistic regression models with interaction terms for race-ethnicity and income.

Results: For each perinatal time point, all categories of racial-ethnic minority women experienced higher rates of uninsurance than white non-Hispanic women. From preconception to postpartum, 75.3% (95% CI 74.7-75.8) of white non-Hispanic women had continuous insurance compared with 55.4% of black non-Hispanic women (95% CI 54.2-56.6), 49.9% of indigenous women (95% CI 46.8-53.0) and 20.5% of Hispanic Spanish-speaking women (95% CI 18.9-22.2). In adjusted models, lower-income Hispanic women and indigenous women had a significantly higher predicted probability of uninsurance in the preconception and postpartum period compared with white non-Hispanic women.

Conclusion: Disruptions in perinatal insurance coverage disproportionately affect indigenous, Hispanic, and black non-Hispanic women. Differential insurance coverage may have important implications for racial-ethnic disparities in access to perinatal care and maternal-infant health.

Figures

Fig. 1.. Insurance status by time period…
Fig. 1.. Insurance status by time period and race–ethnicity. Data are weighted proportions; other, mixed, or unknown race–ethnicity not shown.
Daw. Racial–Ethnic Disparities in Perinatal Insurance Coverage. Obstet Gynecol 2020.
Fig. 2.. Insurance continuity from preconception to…
Fig. 2.. Insurance continuity from preconception to postpartum by race–ethnicity. Data are weighted proportions; other, mixed, or unknown race–ethnicity not shown.
Daw. Racial–Ethnic Disparities in Perinatal Insurance Coverage. Obstet Gynecol 2020.
Fig. 3.. Adjusted predicted probability of uninsurance…
Fig. 3.. Adjusted predicted probability of uninsurance by time period, race–ethnicity, and household income. Preconception (A), delivery (B), and postpartum (C). Data are predicted probabilities calculated based on a logistic regression model adjusted for age, education, marital status, state of residence, household income, and an interaction term between household income and race–ethnicity; all covariates held at sample observed values. Bars represent 95% CIs. Asian or Pacific Islander and other, mixed, or unknown race–ethnicity are not shown.
Daw. Racial–Ethnic Disparities in Perinatal Insurance Coverage. Obstet Gynecol 2020.

References

    1. Petersen EE, Davis N, Goodman D, Cox S. Racial/ethnic disparities in pregnancy-related deaths—United States, 2007–2016. Morb Mortal Wkly Rep 2019;68:762–65.
    1. Admon LK, Winkelman TNA, Zivin K, Terplan M, Mhyre JM, Dalton VK. Racial and ethnic disparities in the incidence of severe maternal morbidity in the United States, 2012–2015. Obstet Gynecol 2018;132:1158–66.
    1. Creanga AA, Berg CJ, Syverson C, Seed K, Bruce FC, Callaghan WM. Race, ethnicity, and nativity differentials in pregnancy-related mortality in the United States: 1993-2006. Obstet Gynecol 2012;120:261–8.
    1. Petersen EE, Davis NL, Goodman D. Pregnancy-related deaths, United States, 2011–2015, and strategies for prevention, 13 states, 2013–2017. Morb Mortal Wkly Rep 2019;68:423–9.
    1. Eisenberg JM, Power EJ. Transforming insurance coverage into quality health care: voltage drops from potential to delivered quality. JAMA 2000;284:2100–7.
    1. Martin JA, Hamilton BE, Osterman MJ, Driscoll A, Drake P. Births: final data for 2016. Natl Vital Stat Rep 2018;67:1–54.
    1. D'Angelo D, Le B, O'Neil ME, Williams L, Ahluwalia IB, Harrison LL, et al. Patterns of health insurance coverage around the time of pregnancy among women with live-born infants—pregnancy risk assessment monitoring system, 29 states, 2009. Morb Mortal Wkly Rep 2015;64:1–19.
    1. Shulman HB, D'Angelo DV, Harrison L, Smith RA, Warner L. The pregnancy risk assessment monitoring system (PRAMS): overview of design and methodology. Am J Public Health 2018;108:1305–13.
    1. Daw JR, Kozhimannil K, Admon LK. High rates of perinatal insurance churn persist after the ACA. Health Affairs Blog. Available at: /. Retrieved September 24, 2019.
    1. Artiga S, Arguello R, Duckett P. Health coverage and care for American Indians and Alaska natives. Available at: . Retrieved December 9, 2019.
    1. National Center for Health Statistics. Long-term trends in health insurance: estimates from the national health interview survey, United States, 1968–2018. Available at: . Retrieved December 9, 2019.
    1. Montoya-Williams D, Burris H, Fuentes-Afflick E. Perinatal outcomes in Medicaid expansion and nonexpansion states among Hispanic women. JAMA 2019;322:893–4.
    1. DeSisto CL, McDonald JA. Variation in birth outcomes by mother's country of birth among Hispanic women in the United States, 2013. Public Health Rep 2018;133:318–28.
    1. McMorrow S, Johnston EM, Steedle R, Thomas T. Health insurance coverage for women of reproductive age, 2013–2016. Available at: . Retrieved October 28, 2019.
    1. Thomson MD, Hoffman-Goetz L. Defining and measuring acculturation: a systematic review of public health studies with Hispanic populations in the United States. Soc Sci Med 2009;69:983–91.
    1. Carter-Pokras O, Zambrana RE, Yankelvich G, Estrada M, Castillo-Salgado C, Ortega AN. Health status of Mexican-origin persons: do proxy measures of acculturation advance our understanding of health disparities? J Immigr Minor Health 2008;10:475–88.
    1. Sommers BD, Gourevitch R, Maylone B, Blendon RJ, Epstein AM. Insurance churning rates for low-income adults under health reform: lower than expected but still harmful for many. Health Aff (Millwood) 2016;35:1816–24.
    1. Federico SG, Steiner JF, Beaty B, Crane L, Kempe A. Disruptions in insurance coverage: patterns and relationship to health care access, unmet need, and utilization before enrollment in the state children's health insurance program. Pediatrics 2007;120:e1009–16.
    1. Lavarreda SA, Gatchell M, Ponce N, Brown ER, Chia YJ. Switching health insurance and its effects on access to physician services. Med Care 2008;46:1055–63.
    1. Daw JR, Hatfield LA, Swartz K, Sommers BD. Women in the United States experience high rates of coverage “churn” in months before and after childbirth. Health Aff (Millwood) 2017;36:598–606.
    1. Passel JS, Cohn D. Number of babies born to unauthorized immigrants in U.S. continued to decline in 2014. Available at: . Retrieved August 16, 2017.
    1. Kaiser Family Foundation. Health coverage of immigrants. Available at: . Retrieved April 16, 2018.
    1. Baldwin LM, Grossman DC, Casey S, Hollow W, Sugarman JR, Freeman WL, et al. Perinatal and infant health among rural and urban American Indians/Alaska Natives. Am J Public Health 2002;92:1491–7.
    1. Castor ML, Smyser MS, Taualii MM, Park AN, Lawson SA, Forquera RA. A nationwide population-based study identifying health disparities between American Indians/Alaska Natives and the general populations living in select urban counties. Am J Public Health 2006;96:1478–84.
    1. Kaiser Family Foundation. Where are states today? Medicaid and CHIP eligibility levels for children, pregnant women, and adults. Available at: . Retrieved May 1, 2019.
    1. Baumeister L, Marchi K, Pearl M, Williams R, Braveman P. The validity of information on “race” and “Hispanic ethnicity” in California birth certificate data. Health Serv Res 2000;35:869–83.
    1. Reichman NE, Hade EM. Validation of birth certificate data: a study of women in New Jersey's HealthStart program. Ann Epidemiol 2001;11:186–93.
    1. Mason LR, Nam Y, Kim Y. Validity of infant race/ethnicity from birth certificates in the context of U.S. demographic change. Health Serv Res 2014;49:249–67.
    1. American College of Obstetricians and Gynecologists. ACOG statement on AMA support for 12 months of postpartum coverage under Medicaid. Available at: . Retrieved August 2, 2019.
    1. American Medical Association. AMA adopts new policies at 2019 annual meeting. Available at: . Retrieved October 21, 2019.
    1. . H.R.4996: Helping MOMS Act of 2019. 116th Congress. Available at: . Retrieved December 10, 2019.
    1. Ranji U, Gomez I, Salganicoff A. Expanding postpartum Medicaid coverage. Available at: . Retrieved August 7, 2019.
    1. Peahl A, Kozhimannil K, Admon LK. Addressing the US maternal health crisis: policies of 2020 presidential candidates. Health Affairs Blog. Available at: . Retrieved June 26, 2019.
    1. . S.3494:MOMMIES Act. 115th Congress. Available at: . Retrieved October 21, 2019.
    1. . H.R.1897 MOMMA's Act. 116th Congress. Available at: . Retrieved October 21, 2019.
    1. Admon LK, Winkelman TNA, Moniz MH, Davis MM, Heisler M, Dalton VK. Disparities in chronic conditions among women hospitalized for delivery in the United States, 2005-2014. Obstet Gynecol 130;2017:1319–26.
    1. Prepregnancy counseling. ACOG Committee Opinion No. 762. American College of Obstetricians and Gynecologists. Obstet Gynecol 2019;133:e78–89.

Source: PubMed

Sponsorer och medarbetare

Medicinska tillstånd

Läkemedelsinterventioner

3
Prenumerera