Study Examines Maternal Health Care Disparities by Immigrant, Medicaid Status

Study findings released Friday illustrate how policies surrounding Medicaid coverage for prenatal care and pregnancy can lead to increased health care disparities among some immigrant groups.

Under federal law, immigrants who are noncitizens and pregnant, and their children, are excluded from Medicaid and the Children’s Health Insurance Program (CHIP) for 5 years unless states decide to opt them in.

In this study, published in JAMA Network Open, researchers used birth data from 2011-2019 to estimate the link between exclusion from nonpregnancy Medicaid coverage and access to prenatal care in immigrant women.

Their assumption was that in states that expanded Medicaid in 2014 as part of the Affordable Care Act, the rate of timely prenatal care would rise for women born in the United States but not for women who were immigrants, creating a left-behind effect. Timely prenatal care was defined as care that began in the first trimester.

They conducted a cross-sectional difference-in-differences (DID) and triple-difference analysis of 22,042,624 singleton births from January 1, 2011, to December 31, 2019, in 31 states (16 states that expanded Medicaid and 15 that did not).

Individual-level covariates included age, parity, race and ethnicity, and educational level; state-level time-varying covariates included unemployment, poverty, and the Immigrant Climate Index.

Analyses were stratified by race and ethnicity, and analysis was performed from February 1, 2021, to August 24, 2022.

Within 16 states that expanded Medicaid, the rate of timely prenatal care by nativity in years after expansion was compared with the rate in the years before expansion. Similar comparisons were conducted in 15 states that did not expand Medicaid and tested across expansionvs nonexpansion states.

The analysis included 5,390,814 women preexpansion and 6,544,992 women postexpansion.

Before expansion: At baseline in expansion states, among immigrant women, 413,479 (27.3%) were Asian, 110,829 (7.3%) were Black, 752,176 (49.6%) were Hispanic, and 238,746 (15.8%) were White.

Among US-born women, 96,807 (2.5%) were Asian, 470,128 (12.1%) were Black, 699,776 (18.1%) were Hispanic, and 2,608,873 (67.3%) were White.

Prenatal care was timely in 75.9% of immigrant women vs 79.9% of those who were US born in expansion states at baseline.

After expansion: The immigrant vs US-born disparity in prenatal care was similar to the preexpansion level (DID,–0.91; 95% CI, –1.91 to 0.09).

However, stratifying by race and ethnicity showed disparities for both Asian and Hispanic populations.

After expansion, there was an increase in Asian vs White disparity with 1.53 per 100 fewer immigrant women, compared witth those who were US born, accessing prenatal care (95% CI, –2.31 to –0.75), and the Hispanic vs White disparity was –1.18 per 100 women (95% CI, –2.07 to –0.30).

The differences were more striking among women with a high school education or less for both Asian and Hispanic women (DID for Asian women, –2.98; 95% CI, –4.45 to –1.51; DID for Hispanic women, –1.47; 95% CI, –2.48 to –0.46).

Compared with nonexpansion states, differences in DID estimates were found among Hispanic women with a high school education or less (triple difference, –1.86 per 100 additional women in expansion states who would not receive timely prenatal care; 95% CI, –3.31 to –0.42).

The left-behind effect remained after controlling for time-varying state-level poverty, unemployment, and policies toward immigrants.

"The findings of this study suggest that exclusions from Medicaid eligibility based on immigration status may be associated with increased health care disparities," the researchers said.

Reference

Janevic T, Weber E, Howell FM; Steelman M, Krishnamoorthi M, Fox A. Analysis of state Medicaid expansion and access to timely prenatal care among women who were immigrant vs US born. JAMA Netw Open. 2022;5(10):e2239264. doi:10.1001/jamanetworkopen.2022.39264