Rural-Urban Differences in Coverage Gains Under Continuous Postpartum Medicaid Eligibility

Rural residents face higher rates of obstetric complications, yet are more likely to lose insurance after childbirth, limiting access to essential postpartum care. This study examined whether continuous Medicaid eligibility during the COVID-19 public health emergency (PHE) differentially impacted postpartum insurance coverage in rural versus urban populations.

Using data from the 2017-2022 American Community Survey, we evaluated how state-level variation in pregnancy-related Medicaid eligibility during the PHE influenced coverage among rural and urban residents in the postpartum period.

Medicaid coverage increased significantly for both rural and urban populations. Adjusting for sociodemographic factors and COVID-19 disease burden, rural mothers experienced a 6.4 percentage-point (pp) greater gain in Medicaid coverage per 100-pp increase in the state's pregnancy-related eligibility threshold (95% confidence interval [CI] [1.6, 11.2] pp). Overall postpartum insurance coverage also rose in both groups, although the increase was not significantly larger among rural mothers (3.2-pp greater gain; 95% CI [-0.4, 6.8]).

These findings suggest that recently adopted postpartum Medicaid extensions may yield larger increases in Medicaid coverage in rural communities, an important consideration for policymakers seeking to mitigate the impact of impending Medicaid budget constraints on rural populations.