A recent study found immigrants are less likely to receive postpartum care in states that restrict insurance coverage.
Immigrants in states that restrict public insurance coverage for undocumented and recent immigrants are less likely to receive postpartum care compared with immigrants in states without such restrictions, according to a cross-sectional analysis published in the Journal of the American Medical Association.
The analysis used data from the Pregnancy Risk Assessment Monitoring System (PRAMS) for 19 states and New York City, New York, comprising 72,981 adults with low income who had a live birth between 2012 and 2019. Overall, 29% of these adults were immigrants and 71% were not.
States were divided into 3 categories of insurance coverage: full coverage (publicly funded postpartum care, regardless of immigration status), moderate coverage (publicly funded postpartum care to lawfully residing immigrants without a 5-year waiting period but no postpartum care to undocumented immigrants), and no coverage (no publicly funded postpartum care to lawfully present immigrants before 5 years of legal residence or to undocumented immigrants). Among the 19 states and New York City, 6 offered full coverage, 9 offered moderate coverage, and 4 offered no coverage. The remaining state, Oregon, converted from moderate coverage to full coverage during the study period.
Compared with states that offered full insurance coverage, receipt of postpartum care among immigrants was 7% lower in states that offered moderate coverage and 11.3% lower in states that offered no coverage. Similarly, there was a 3.3 percentage point larger difference between immigrants and nonimmigrants in states that provided moderate coverage and a 7.7 percentage point larger difference in states that provided no coverage.
Neither principal investigator Maria Steenland, ScD, nor Laura Wherry, PhD, the major coresearcher on the study, are surprised by the findings. Steenland is an assistant professor of health services, policy, and practice at Brown University in Providence, Rhode Island, and Wherry is an associate professor of economics and public service at Robert F. Wagner Graduate School of Public Service at New York University in New York City. “[Findings from] most other studies have found that having insurance coverage is associated with increased health service use,” Steenland told Contemporary OB/GYN.
Steenland noted that the size of the difference between states with the most and least restrictive policies was roughly 11 percentage points, “which is large, but not a huge difference. However, we compared all immigrants between state coverage categories, including both immigrants who would be affected by the policies—undocumented immigrants and legal permanent residents with fewer than 5 years with this status—and other immigrants who might be citizens or long-term permanent residents. Because some people in our study population would not be impacted by the policies, we knew that our findings were likely to be attenuated.”
Reduced access to postpartum care for immigrants may decrease diagnosis and management of postpartum depression and other common causes of postpartum morbidity, according to Steenland. “Limited postpartum care could also result in less well-controlled diabetes and hypertension, [because] the postpartum visit is used to identify and refer patients for ongoing chronic disease care,” she said. “Missed opportunities for the…management of chronic health conditions could have important implications for the long-term health of these immigrant parents and birth outcomes for any future pregnancies.”
On the other hand, several states have recently extended Medicaid pregnancy coverage from 60 days postpartum to 12 months postpartum. “Although many immigrants are covered under this extension, undocumented postpartum immigrants will not be eligible in most states,” Steenland said.
To date, 7 states (California, Illinois, Maryland, Massachusetts, Minnesota, Rhode Island, and Washington) have extended postpartum coverage regardless of immigration status. “In other states, excluding undocumented immigrants from the 12-month extension will likely exacerbate existing disparities in insurance coverage and health care access between US-born and undocumented individuals,” Steenland said.
Steenland MW, Fabi RE, Bellerose M, Desir A, White MS, Wherry LR. State public insurance coverage policies and postpartum care among immigrants. JAMA. Published online July 18, 2023. doi:10.1001/jama.2023.10249