The Association Between Continuity of Marketplace Coverage During Pregnancy and Receipt of Prenatal Care

The Association Between Continuity of Marketplace Coverage During Pregnancy  and Receipt of Prenatal Care | The Incidental Economist

Pregnancy is a significant life event, one that typically leads to substantially more interaction with the health care system than average. In the United States (US), pregnant people usually have about one health care visit per month of pregnancy, during which they receive a myriad of services. However, access to high quality prenatal care — and enough of it — is often limited by one’s health insurance coverage.

When the Affordable Care Act was enacted, it established the individual Marketplaces from which those who are ineligible for Medicaid, Medicare, and/or employer-sponsored insurance can purchase coverage. However, pregnancy is not considered a qualifying life event, so an individual cannot just sign up for coverage once they find out they’re pregnant; they must wait until the next open enrollment period or the birth of their child, whichever comes first. Thus, they may be stuck without coverage during pregnancy. This can have a significant impact on access to appropriate prenatal care.

New Research

recent study in Health Affairs looked at Marketplace enrollment patterns for pregnant people and the impact of Marketplace insurance coverage on their health and care utilization.

The authors are Sarah Gordon and Melissa Garrido from Boston University School of Public Health (BUSPH) Health, Law, Policy, and Management Department (HLPM) and VA Boston Healthcare System; Charlotte Alger from BUSPH HLPM; and Eugene Declercq from BUSPH Community Health Sciences Department.

The authors used data from the Pregnancy Risk Surveillance and Monitoring System (PRAMS) from 2016 to 2018. Developed by the Centers for Disease Control and Prevention, PRAMS is a self-reported survey within 40 states and New York City and is representative of 83 percent of all US births. State health departments pull a representative sample of recent births from birth certificate registries and reach out via mail and telephone to the selected mothers. The survey asks respondents about health status and behaviors, health care use, and insurance coverage.

With these data, they studied two questions. First, they assessed how likely pregnant people were to be enrolled in Marketplace insurance coverage preconception, during pregnancy, and/or postpartum. Sample size for this question was 6491 and the authors used simple descriptive analysis techniques.

Second, they studied how Marketplace enrollment impacted individuals’ receipt of prenatal care, such as the number of prenatal visits, receipt of care within the first trimester, and receipt of specific health care services like flu shots and screenings for intimate partner violence and depression. The sample size for this question was 3443, limited to individuals who reported Marketplace coverage during pregnancy. The authors used logistic regression models and inverse probability of treatment weights to conduct these analyses.


For enrollment, the authors found that about one third of respondents had continual Marketplace coverage, from preconception to postpartum. Of those who were only enrolled in the Marketplace preconception, over 70 percent reported Medicaid coverage during pregnancy. Of those who were only enrolled in the Marketplace postpartum, almost 50 percent reported Medicaid coverage and one third reported employer-sponsored insurance coverage during pregnancy.

For impact of enrollment during pregnancy, the authors compared those with continuous coverage (preconception to postpartum) to those who only enrolled in the Marketplace during pregnancy. Those with continuous Marketplace coverage were more likely to have “adequate” or “more than adequate” prenatal care use. (The authors defined these classifications using the Adequacy of Prenatal Care Utilization Index which measures timing and quantity of care.) Those with continuous coverage were also more likely to initiate prenatal care in the first trimester, though over 80 percent of respondents in both groups did so. The authors did not find any significant differences in the likelihood of receipt of particular prenatal services, such as flu shots or social/mental health screenings.


There were several limitations to this study due to the nature of the PRAMS data set. For example, PRAMS is self-reported, subject to both recall bias and response bias. Plus, the survey is not conducted in all states and, thus, assumptions must be made about generalizability. Lastly, PRAMS simply includes a finite set of questions; this is certainly understandable but does limit researchers’ analyses.


With the connection between insurance coverage and access to care clear, several notable policy questions arise from this study. Classifying pregnancy as a qualifying life event is perhaps the most obvious. As mentioned previously, pregnancy is not a qualifying life event, though the birth of a child is. (Only two states have implemented policies to the contrary.) Allowing an individual to sign up for health insurance coverage once pregnant, rather than waiting until birth or the next open enrollment period, could improve access to prenatal care and even improve maternal and child health outcomes.

Another related policy implication is determining what type of insurance is ideal for pregnant individuals. The authors found that individuals without Marketplace coverage often have other types of coverage, at least temporarily. What type of insurance is best or most cost-effective for pregnant people — and the benefits of coverage continuity regardless of type — could be studied further.

The study did not touch on the quality of prenatal care but that is also worth discussion. In the US, pregnant people tend to receive far more prenatal care than other countries but that doesn’t mean the quality is better, nor do maternal health outcomes suggest that’s true. In fact, the US’ maternal health outcomes are some of the worst in the industrial world.

Pregnancy is full of changes, expenses, and challenges. Determining how Marketplace insurance coverage — which has been around for a decade — access to care, and maternal and child health outcomes all interact from preconception to postpartum warrants more study.

3 healthcare executive actions expected from Biden this week

Biden sets agenda on Day One with executive actions |

President Joe Biden is expected to sign executive actions this week related to immigration, healthcare and climate, according to a memo obtained by The Hill.

The executive actions would follow 10 he signed Jan. 21 to combat COVID-19 spread.

Here are the three healthcare executive actions to expect Jan. 28, according to The Hill

1. President Biden is set to rescind a policy banning foreign aid for abortion, known as the Mexico City policy. It prohibits the use of U.S. funds for foreign and national health organizations that perform or actively promote abortion, according to NBC News. The policy was announced by former President Ronald Reagan in 1984. According to The Hill, it has been rescinded by Democratic presidents and reinstated by Republican presidents, including former President Donald Trump, since then.

2. President Biden will also call for a review of the Title X family planning program, according to a memo obtained by The Hill. The federal program provides family planning and related preventive health services for low-income or uninsured people and others. In 2019, the Trump administration issued a final rule prohibiting providers that receive federal family planning money under the program from providing or promoting abortions. NBC News reported that the Biden administration is expected to back off this rule and “restore federal funding for Planned Parenthood,” which left the program in 2019.

3. President Biden plans to sign an executive action on Medicaid and initiate an open enrollment period under the ACA, according to a memo obtained by The Hill. The annual open enrollment period for 2021 closed in December. However, President Biden could initiate a special enrollment period. 

How Pending Decision on Obamacare Could Upend 2020 Campaign

Supporters of expanding Medicare at a town hall meeting this summer in Forked River, N.J.  Health care registers as a top priority for voters in poll after poll.

A federal appeals court’s ruling on the Affordable Care Act could be a huge headache for the president and take Democrats’ focus off Medicare for all.

 A federal appeals court in New Orleans is preparing a ruling on the Affordable Care Act that could put the law’s future front and center in the presidential race, overwhelming the current Democratic debate over Medicare for all and reigniting the health care-driven worries that helped Democrats win back the House last year.

Three judges on the Fifth Circuit Court of Appeals are weighing whether to uphold a Texas judge’s ruling that the law’s requirement for most Americans to have health insurance is unconstitutional, and that the rest of the sprawling law cannot function without it. It is hard to imagine a thornier domestic issue for President Trump, whose administration not only refused to defend the law in the case filed by Texas and 19 other states but sided with the plaintiffs, asking the court to invalidate it.

A ruling against Barack Obama’s signature domestic achievement as president, which provides health coverage for about 24 million Americans, would almost certainly be stayed pending further appeal.

But if it comes in the next few weeks, it could create significant confusion during open enrollment for the Obamacare plans offered through the law’s online marketplaces. And it would open a huge vulnerability for Mr. Trump, whose health care platform largely consists of attacking as socialism Democratic plans to expand government health care, either through Medicare for all or a government-run health care option that would be offered through the Affordable Care Act’s marketplaces.

A ruling against the health law would probably reframe the Democratic conversation on health policy away from moving beyond the Affordable Care Act toward Republican efforts to take health care away. That message, a driving force in the 2018 midterm campaigns, could resonate more broadly than the party’s current arguments over expanding coverage.

“Democrats will do better talking about what Trump can take away than about their new policy visions,” said Chris Jennings, a longtime Democratic adviser on health care. “The Texas case may reframe discourse around health policy more toward that type of discussion, which of course Republicans will hate.”

The law’s most popular provision is protections for people with pre-existing medical conditions, but it includes much more, such as health insurance exchanges where people can buy private coverage with subsidies, an expansion of Medicaid and requirements for what insurance must cover, from emergency services to prescription drugs.

The appeals court panel could decide to partly reverse Judge Reed O’Connor of the Federal District Court in Fort Worth, affirming that the mandate that most Americans have health insurance is unconstitutional but rejecting Judge O’Connor’s ruling that the rest of the law cannot stand without it. That would cause barely a ripple, because the tax penalty for not having insurance was reduced to zero in the 2017 tax overhaul and the effects have been negligible.

But a ruling that upheld his decision in full, or even one that said the mandate and pre-existing condition protections had to go, would send shock waves through the health care and political systems. Either outcome would probably play into Democratic hands, especially in contests against vulnerable Republicans like Senators Martha McSally of Arizona, Cory Gardner of Colorado, Susan Collins of Maine and Thom Tillis of North Carolina.

Republicans are not conceding that possibility. Asked how a ruling against the law might affect members of the party seeking re-election, the spokesman for the House Republican campaign arm, Chris Pack, said: “Both Democrats and Republicans oppose Obamacare. The only difference is that Democrats want to replace it with socialized single-payer health care that makes private health insurance illegal.”

In fact, most Democrats would welcome a renewed debate over the Affordable Care Act. Many Democrats in Congress have resisted Medicare for all; instead they have sought to shore up the existing health law and trap Republicans on pre-existing conditions. Senator Chuck Schumer of New York, the Democratic leader, intends to force a floor vote as soon as next week on a resolution to overturn a Trump rule that lets states promote skimpy-but-inexpensive insurance plans that do not meet the law’s coverage standards.

The vote, Mr. Schumer said Tuesday on the Senate floor, “will present our Republican colleagues with a choice: whether to protect Americans with pre-existing conditions or not to protect them.”

Mr. Trump is in a box on health care, the issue that registers as a top priority for voters in poll after poll. He wants deals on ending surprise medical bills and lowering prescription drug prices, but the Senate and House are far apart on what drug price legislation they would agree to, and impeachment proceedings could derail any chance of bipartisan measures.

Public support for the health law remains high, driven in part by swing voters. And few Americans believe Mr. Trump will offer details of a new health care plan before the end of the year, according to a Kaiser poll released this week. They also doubt any plan he releases would offer “better care at lower costs,” as he has promised.

Alex M. Azar II, the secretary of health and human services, has repeatedly played down the importance of expanding coverage to the remaining uninsured; instead, he has said, Mr. Trump wants to improve the health care system for all Americans. His efforts thus far have mostly been directed at discrete groups of patients: a plan to reduce new H.I.V. infections by 75 percent over five years, for example, and another to move people with advanced kidney disease to home-based, instead of clinic-based, dialysis.

At oral arguments before the appeals court panel in July, a lawyer from the Justice Department indicated the Trump administration would seek a stay if the panel upheld Judge O’Connor’s decision. The losing side could appeal directly to the Supreme Court, increasing the chances of a ruling or at least oral arguments before that court in the final months of the presidential campaign. Alternatively, it could first ask for a hearing by the full appeals court, which would slow down the process.

The appeals panel could also send the case back to Judge O’Connor to reconsider, an option that August Flentje, a lawyer for the Justice Department, embraced during oral arguments. That would also draw out the court fight.

When the six-week open enrollment period starts next month, there will be more insurers offering plans through the Affordable Care Act markets. Premiums have stabilized, too, after a few years of price increases. But it will be a much lower-profile effort than in past years; the Trump administration has cut the budget for both advertising and enrollment help. As a result, a court ruling against the law would paralyze open enrollment if people assume there is no use buying or renewing coverage under a law that was ruled unconstitutional, and if no effort is mounted to counter that misunderstanding.

“It will require a doubling down, a dramatic increase in education — which is exactly the opposite of what this administration has done,” said Leslie Dach, executive director of Protect Our Care, a consumer advocacy group aligned with Democrats. “Someone will need to educate people that low-cost, quality health insurance is still available to them.”