More than one-third of insured Massachusetts individuals changed insurance type during the perinatal period

More than one in three continuously insured individuals in Massachusetts experienced a health insurance transition during the 12 months before or after giving birth, according to a University of Massachusetts Amherst study.

The study, published in JAMA Network Open, analyzed data from more than 97,000 births from 2015 through 2017. The findings suggest that further research is important to examine the impact of insurance transitions on perinatal care and outcomes.

"It's really important during the perinatal period for the mom and the baby to have insurance," says lead author Chanup Jeung, a postdoctoral associate in the School of Public Health and Health Sciences. "Switching insurance plans disrupts the continuity of care even for those who remain insured during the perinatal period, and it may reduce the access to care."

The most common transitions involved moving in and out of Medicaid and Medicaid managed care coverage, compared to commercial insurance. Medicaid is run by the state and Medicaid managed care is administered by private, usually nonprofit companies.

Previous research has shown that continuous insurance helps improve birth outcomes and reduce perinatal morbidity and mortality. This is the first look at how many continuously insured Massachusetts residents change insurance types during this critical period.

"Our study gives a different perspective," Jeung says. "We're thinking this kind of insurance transition—even for continuously insured people—may affect their outcomes."

Senior author Kimberley Geissler, associate professor of health policy and management, says the research team did a lot of digging to try to determine the various causes of the insurance transitions.

"One way people can move is because they want to change insurer or they want to change providers," she says. "The other reason is because of Medicaid redeterminations."

For example, Medicaid requirements are based on ever-changing factors, such as income, family size, marital and employment status, as well as pregnancy status.

Of the 97,335 deliveries included in the study, about 45% were covered by private insurance, 23.4% by Medicaid, 28.1% by Medicaid managed care and between 3.1% and 4.5% by Marketplace plans.

The analysis of the data revealed that 37.1% of the insured had a transition at some point in the 12 months before and/or after delivery. Among those with an insurance change, 24% had postpartum insurance transitions only, 38.8% had pre-delivery transitions only and 37.2% had both pre-delivery and postpartum transitions. Individuals with Medicaid and Medicaid managed care were 47 percentage points and 50.1 percentage points more likely, respectively, to have an insurance transition than those covered by private insurance.

"We know from the literature that these transitions happen, but I was surprised by how common they are, and also that they're common across insurance types," Geissler says. "People who are privately insured are less likely to have a transition, but they are not immune from these transitions."

The research was part of a larger project supported by the Commonwealth Fund that is looking at the impact of the transition to Medicaid accountable care organizations (ACOs) in Massachusetts on maternal outcomes and postpartum care. This study was looking at births before ACOs went into effect.

"This is an important step in understanding Medicaid coverage during this period," Geissler says.

Almost all people in Massachusetts are covered by health insurance, the researchers point out. This study is relevant nationwide as other states seek to expand their rate of health insurance coverage, particularly during the perinatal period.

"There is intense policy interest in covering people during pregnancy and postpartum because of the issues surrounding maternal mortality and morbidity," Geissler says. "Massachusetts can give us some sense of what will happen in other states as they expand coverage."