Morbidity and Mortality Weekly Report (MMWR)

MMWR

Patterns of Health Insurance Coverage Around the Time of Pregnancy Among Women with Live-Born Infants — Pregnancy Risk Assessment Monitoring System, 29 States, 2009

Corresponding author: Denise D'Angelo, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. Telephone: 770-488-6288; E-mail: DDAngelo@cdc.gov.

MMWR in Brief summarizes key points from Patterns of Health Insurance Coverage Around the Time of Pregnancy Among Women with Live-Born Infants–Pregnancy Risk Assessment Monitoring System, 29 States, 2009. MMWR Surveill Summ 2015;64(No. SS-4).Available at http://www.cdc.gov/mmwr/pdf/ss/ss6404.pdf. Certain text might not have appeared in the original publication.

New Information

This report summarizes state-based data on the prevalence of health insurance coverage stability around the time of pregnancy among women who had a recent live birth in 2009, which can be used to assess and monitor changes in health insurance patterns following the passage of the Patient Protection and Affordable Care Act (ACA).

Analysis

The prevalence of coverage stratified by type (stable private coverage, stable Medicaid coverage, unstable coverage, and uninsured) across three time periods (the month before pregnancy, during pregnancy, and at the time of delivery) is reported by state and overall. Patterns of movement between the different types of health insurance coverage among women with unstable coverage also are described.

Summary Findings

Three of 10 women who had a live birth in 2009 experienced changes in health insurance coverage between the month before pregnancy and the time of delivery, either because they lacked coverage at some point or because they moved between different types of coverage.

Data Source and Methods

The Pregnancy Risk Assessment Monitoring System (PRAMS) is an ongoing state- and population-based surveillance system designed to monitor selected self-reported maternal behaviors and experiences that occur before, during, and after pregnancy among women who deliver a live-born infant. Using a standardized data collection methodology involving a mailed questionnaire and telephone interviews for mail nonrespondents, the survey is conducted by participating health departments.

Weighted data from 29 states were used to calculate prevalence estimates and 95% confidence intervals (Figure). Women classified as having stable coverage had the same type of health insurance (private or Medicaid) for all three time periods. Women classified as having unstable coverage experienced a change in health insurance coverage between any of the three time periods. Patterns of movement between different types of health insurance coverage includes movement from having no insurance coverage to gaining coverage, movement from one type of coverage to another, and loss of coverage.

Main Results

The PRAMS survey in the 29 selected states in 2009 had 40,388 respondents; after exclusion criteria was applied, the final sample size for this analysis was 36,710. Nearly one third (30.1%) of women who had a live birth in 2009 experienced changes in health insurance coverage between the month before pregnancy and the time of delivery. Most women had stable coverage across the three time periods, reporting either private coverage (52.8%) or Medicaid coverage (16.1%) throughout. A small percentage of women (1.1%) reported having no health insurance coverage at any point.

Overall, Medicaid coverage increased from 16.6% in the month before pregnancy to 43.9% at delivery. Private coverage decreased from 59.9% in the month before pregnancy to 54.6% at delivery. The percentage of women who were uninsured decreased from 23.4% in the month before pregnancy to 1.5% at the time of delivery.

Among those who experienced changes in coverage, 74.4% reported having no insurance the month before pregnancy, 23.9% reported having private insurance, and 1.8% reported having Medicaid (Table). Among those who were uninsured before pregnancy, 70.2% reported Medicaid coverage and 4.1% reported private coverage at the time of delivery. Among those who had private coverage before pregnancy, 21.3% reported Medicaid coverage at delivery and 1.4% reported being uninsured. Most (92.4%) women who experienced a change in health insurance around the time of pregnancy reported Medicaid coverage at delivery. No women with unstable coverage who did not have insurance in the month before pregnancy reported being uninsured at the time of delivery.

Limitations

The findings in this report are subject to at least three limitations. First, because PRAMS data are not available from all states, the results of this report are not generalizable to the entire United States. Second, the information on insurance coverage status was self-reported by PRAMS respondents several months after delivery. Finally, broad categories were used for insurance coverage; specifically, women with military insurance coverage were categorized as part of the private insurance group, and women reporting IHS coverage were categorized as part of the uninsured group.

Public Health Implications

In 2009, approximately one third of women reported lacking health insurance or transitioning between types of health insurance coverage around the time of pregnancy. The majority of women who changed health insurance status obtained coverage for prenatal care, delivery, or both through Medicaid. Health insurance coverage during pregnancy (prenatal coverage) can help facilitate access to health care and allow for the identification and treatment of health-related issues. Continuous access to health insurance and health care for women of reproductive age can improve maternal and infant health by early identification and management of conditions that are present before and between pregnancies. ACA implementation varies by state and includes provisions to address lack of coverage for low-income, nonpregnant adults as well as provisions to address challenges to purchasing private insurance on the individual market. With the passage of ACA in 2010, women who were previously uninsured or had insurance that did not provide them with adequate coverage might experience better access to health services and better coverage. Changes in health insurance patterns for women around the time of pregnancy after passage of ACA can be assessed and monitored using PRAMS state-specific baseline estimates from 2009.

TABLE. Prevalence of movement between different types of health insurance coverage among women with unstable coverage, by type of coverage the month before pregnancy and type of coverage at delivery — Pregnancy Risk Assessment Monitoring System, 29 states,* 2009
Insurance before pregnancy	Insurance at delivery									Total
	Private			Medicaid			Uninsured			Total
	No.†	%§	(95% CI)	No.	%	(95% CI)	No.	%	(95% CI)	No.	%	(95% CI)
Private	136	1.1	(0.8–1.5)	2,447	21.3	(19.9–22.7)	170	1.4	(1.0–1.8)	2,753	23.9	(22.4–25.3)
Medicaid	148	1.0	(0.7–1.2)	101	0.8	(0.4–1.1)	0	0.0	(0.0–0.0)	249	1.8	(1.3–2.2)
Uninsured	486	4.1	(3.4–4.8)	7,357	70.2	(68.7–71.8)	0	0.0	(0.0–0.0)	7,843	74.4	(72.9–75.8)
Total	770	6.2	(5.4–7.1)	9,905	92.4	(91.5–93.2)	170	1.4	(1.0–1.8)	10,845	100.0	(100.0–100.0)
Abbreviation: CI = confidence interval. * Alaska, Arkansas, Colorado, Delaware, Georgia, Hawaii, Illinois, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Nebraska, New Jersey, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, Tennessee, Texas, Utah, Vermont, Washington, West Virginia, Wisconsin, and Wyoming. † Unweighted sample size. § Weighted percentage.

FIGURE. Pregnancy Risk Assessment Monitoring System sites, 2009

This figure is a map of the United States. The 29 states that collected Pregnancy Risk Assessment Monitoring System (PRAMS) data in 2009 and achieved a weighted response rate of at least 65% are shaded in dark brown: Alaska, Arkansas, Colorado, Delaware, Georgia, Hawaii, Illinois, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Nebraska, New Jersey, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, Tennessee, Texas, Utah, Vermont, Washington, West Virginia, Wisconsin, and Wyoming. PRAMS participating sites that did not meet the 65% response rate threshold in 2009 are shaded tan: Alabama, Florida, Louisiana, New Mexico, New York State and New York City , North Carolina, South Carolina, and Virginia. The remaining states were not sites and are shaded white.

Alternate Text: This figure is a map of the United States. The 29 states that collected Pregnancy Risk Assessment Monitoring System (PRAMS) data in 2009 and achieved a weighted response rate of at least 65% are shaded in dark brown: Alaska, Arkansas, Colorado, Delaware, Georgia, Hawaii, Illinois, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Nebraska, New Jersey, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, Tennessee, Texas, Utah, Vermont, Washington, West Virginia, Wisconsin, and Wyoming. PRAMS participating sites that did not meet the 65% response rate threshold in 2009 are shaded tan: Alabama, Florida, Louisiana, New Mexico, New York State and New York City , North Carolina, South Carolina, and Virginia. The remaining states were not sites and are shaded white.

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