Justification: North Carolina is one of 19 states that chose not to expand Medicaid after passage of the Affordable Care Act. Lack of insurance may be most stark for mothers who qualify financially for Medicaid during their pregnancies and find themselves without coverage in the postpartum period. In North Carolina women lose eligibility for coverage through Medicaid for Pregnant Women at the end of the month that falls equal to or greater than 60 days after the conclusion of pregnancy. Being uninsured at this critical time may put recently postpartum women at increased vulnerability for adverse health outcomes including unintended pregnancy. Little research has shown the causal impact of insurance coverage during the postpartum period on important outcomes such as preterm birth since randomizing coverage is typically impractical. We will leverage a natural experiment in North Carolina that resulted in a markedly different distribution of coverage options during the postpartum period to estimate the causal effects of three different categories of coverage on these outcomes.

Proposed research: We plan an observational study using a linked data source which includes (a) Medicaid claims and enrollment data; and (b) birth certificate data on a sample of all Medicaid-funded births from 2011 through 2017. To increase the robustness of our estimates, we propose comparing: 1) women whose Medicaid coverage continues without interruption beyond the standard postpartum period; 2) women whose Medicaid coverage is interrupted or discontinued in the postpartum period but who enroll in coverage restricted to contraception (Family Planning Waiver); and 3) women whose Medicaid coverage is interrupted or discontinued in the postpartum period and do not enroll in subsequent coverage. We will estimate the causal effects of different types of Medicaid coverage on our utilization and health outcomes in a subsequent pregnancy.
Hypotheses: Women whose Medicaid runs out after pregnancy and are not subsequently enrolled into Medicaid at either coverage level will be more likely to have a preterm birth.

New features:
– Natural experiment
– Nonexpansion state with limited Medicaid coverage
– Highlights importance both of continued Medicaid coverage for women of childbearing age and of Family Planning Waiver programs