In states that have declined to expand Medicaid to all adults with lower incomes, women of childbearing age are more than twice as likely to be without health insurance as those living in expansion states, according to a new analysis by Georgetown University’s Center for Children and Families.
In the 17 states that had not expanded Medicaid by 2019, nearly a fifth of women of childbearing age, which Georgetown defined as ages 18 to 44, were without health insurance, the analysis found. The rate was 9.2% among the expansion states. (Five of those 17 non-expansion states have expanded Medicaid since 2019.)
That disparity helps explain the United States’ dismal maternal mortality rate. The U.S. has the highest maternal mortality rate of all industrialized nations, a problem that the analysis notes is worsening. In 2019, more than 20 women died for every 100,000 live births, a rate increase of 2.7 deaths from the previous year.
Analysts have long identified lack of health insurance, which is a gateway to health care, as a predominant reason for the United States’ low ranking in the deaths of women during and immediately after childbirth.
“State and federal policymakers have an urgent responsibility to address the maternal mortality crisis by expanding Medicaid and closing the coverage gap,” the report concluded.
The report urges states to take advantage of incentives the Biden administration has pushed to expand Medicaid services, particularly for women of childbearing age. One provision in the COVID-19 American Rescue Plan passed in the spring makes it easier for states to extend Medicaid, the public health plan for low-income Americans, for a full year after a woman delivers.
Overall, the Affordable Care Act, particularly its Medicaid expansion, reduced the percentage of young women without health insurance. The Georgetown analysis indicates that among women of childbearing age, the overall uninsurance rate fell from 21% in 2013, the year before most provisions of the ACA kicked in, to 12.3% in 2015.
The uninsurance rate ticked up after that, to 12.9% by 2019, likely the result of various Trump administration actions to undermine former President Barack Obama’s signature law.
The uninsurance rate among those women fell in all states between 2013 and 2019, the Georgetown analysis reported, with the biggest drop—17%—in New Mexico, and the smallest—1%—in Wyoming.
But the rates of uninsurance among women remained highest in the non-expansion states. Texas had the highest rate of uninsurance in that group, with 26.2% of women ages 18 to 44 uninsured, followed by Oklahoma, Mississippi, Wyoming, Florida and Georgia.
The states with the lowest rates all had expanded Medicaid. Massachusetts led the way at 3.6%, trailed by Iowa, Vermont, Hawaii and Rhode Island. Washington, D.C., had the lowest rate of all, 2.4%.
According to the U.S. Census Bureau, in 2019, 36% of the total U.S. population lived in the 17 non-expansion states cited in the Georgetown report. However, the report found that a disproportionate share of uninsured women ages 18 to 44 lived in non-expansion states—53.8%.
And roughly a quarter of uninsured women in that age range in 2019 lived in either of two states, Texas or Florida.
One troubling finding noted in the Georgetown report was the disparity between the uninsured rates for Black and Latina women compared with those for White and non-Latina women. That was the case even in expansion states.
For example, in Maryland, an expansion state, Black women ages 18 to 44 had an uninsurance rate of 7.3%, compared with 5.9% for White women. Latina women in Maryland of the same age range had a 29.8% uninsurance rate, compared with 5.6% for non-Latina women.
While racial disparities existed in expansion states, they were not evident in non-expansion states. In expansion states, the rate of uninsurance among Black women was 9%, compared with 8.3% for White women. However, in non-expansion states, the uninsurance rates for both populations was the same, 18.2%.
The same pattern did not hold for ethnic disparities. In expansion states, Latina women ages 18 to 44 had an uninsurance rate of 17.7%, compared with 7% for non-Latina women. In non-expansion states, Latina women had a rate of 35.5%, compared with 14.6% for non-Latina women.