Invited Commentary: Medicaid Policy and Pregnancy Outcomes-Toward a Reproductive Autonomy Framework

The Medicaid program covers more than 70 million people and is the largest single health insurance payer for pregnancy and delivery in the United States. In this issue of the Journal, Margerison et al. (Am J Epidemiol. 2021;190(8):1488-1498) investigate the extent to which expansion of Medicaid coverage to nonpregnant low-income adults under the Affordable Care Act may have improved prepregnancy or birth outcomes. They found that Medicaid expansions by states were not associated with changes in prepregnancy health, including smoking and obesity. Similarly, there were no changes in preterm birth or small or large size for gestational age attributable to Medicaid expansion. Results were consistent across a range of model specifications and with allowance for different lag times between Medicaid expansion and pregnancy. The results are consistent with prior research finding that pregnancy-specific Medicaid expansions did not uniformly translate to improved pregnancy and birth outcomes. Results should be interpreted in light of the limited contribution that medical services make to overall health and well-being. To reduce the high rates of adverse pregnancy and child health outcomes in the United States, Medicaid policy must move toward a reproductive autonomy framework that shifts the focus away from pregnancy-specific benefits and toward a comprehensive and patient-empowering reproductive health paradigm.