Intended vs. Actual Access to Care: Impact of Healthcare Consolidation on Maternal and Neonatal Outcomes

The Affordable Care Act was intended principally to increase healthcare insurance coverage to uninsured Americans. Ostensibly, 40 million people obtained coverage. However, American maternal mortality has significantly worsened. The overall health curve in conservative leaning states is shifted downward in comparison to liberal ones including COVID mortality, maternal mortality, neonatal mortality, life expectancy, heart disease, pulmonary, and diabetic deaths, obesity, smoking, suicides, and alcohol related auto deaths. Here, we focus on insurance coverage issues related to those outcomes and market alterations produced by Affordable Care Act (ACA) legislation and regulatory actions that may or may not have had unintended consequences.

Using authoritative national public databases, we analyzed 18 health status metrics in the context of Managed Care Organizations market consolidation and Accountable Care Organizations penetration fueled by the Medicaid expansion. We ranked states from best statistics to worst incorporating 10 measures of health access including: hospital beds, patients without examination for over a year, and incidence of maternity care deserts.

There is considerable variation in the USA for both healthcare status and access. Our data show these are highly correlated (r2 = 0.47, p < 0.01). States with the best outcomes have the best access. States with highest healthcare metrics and healthcare access were all traditional liberal "blue states" with greater infrastructure and insurance coverage.

Hospital and clinic realignments created under the ACA appear to have worsened the healthcare of women and children in the USA, particularly for patients of color. Healthcare status and access to services are highly correlated. States allocating more resources for healthcare have better outcomes. Monopoly exemptions under ACA are temporally and statistically correlated with worsening of maternal outcomes across all geographic regions where control and consolidation was permitted or encouraged. Maternity care deserts have significantly disadvantaged women of color and working-class families in rural and urban zones. Further exacerbating the problem is the reduction of physician independence both within and outside of hospital systems.