What will the US election mean for Black-white disparities in maternal and child health?
Written by Tiffany Green, Ph.D. on October 19, 2020
In October 2017, the Los Angeles Times reported the story of Cassaundra Lynn Perkins, a 21-year-old Texas mother who had recently given birth to premature twins. She had been ill throughout her pregnancy, culminating in liver failure and the birth of her twins at just 6 months. Perkins was readmitted to the hospital after giving birth and died 3 days later, leaving behind three children to be raised by her mother.
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Note: It is important to acknowledge that transgender men and nonbinary individuals are also part of the pregnant and birthing populations. However, given the limitations of existing data, this article will focus on outcomes among self-identified cisgender women.
Cassaundra’s life and death are emblematic of wide racial gaps in maternal health in the United States. Non-Hispanic (NH) Black pregnant women are disproportionately more likely than non-Black pregnant women to be disabled, have chronic illnesses, or both.
Compared to NH white females, they are also more than twice as likely to experience life threatening pregnancy complications and approximately 2.5 times more likely to die from pregnancy-related causes.
Like Cassaundra’s twins, Black infants are more likely to be born preterm and with low birth weight relative to white infants. Black infants also experience the highest infant mortality rates of any racial or ethnic group.
The consequences of these health inequities — poorer health and well-being among surviving mothers and long-term adverse impacts on health and labor market outcomes of their children — have important implications for both population health and the U.S. economy at large.
The upcoming U.S. elections are some of the most consequential in recent memory, and healthcare policies that will impact the health of Black females and infants are on the ballot.
Understanding how policy agendas advanced by the Trump-Pence and Biden-Harris administrations might widen or narrow Black-white gaps in maternal and child health is imperative.
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These include policies relating to the Patient Protection and Affordable Care Act (ACA), hospital-level reforms, racial bias in healthcare, and family planning.
While I focus exclusively on healthcare policies here, ensuring equal access to quality care is only a starting point for addressing these longstanding health inequities.
Affordable Care Act
The ACA was landmark legislation designed to expand insurance coverage in the U.S. among low-income populations dramatically.
Several key components of the ACA, including Medicaid expansions — 38 states and the District of Columbia as of October 2020, insurance subsidies and dependent coverage provisions have dramatically decreased rates of uninsurance and financial barriers to care among low-income women of reproductive age.
This is particularly true of women without children, women of color, or both, including Black women. The ACA also mandates that insurance companies cover essential reproductive health services such as maternity care.
Since the beginning, the Trump administration has worked to scale back Medicaid and overturn the ACA, primarily through executive orders. The Supreme Court is set to hear oral arguments in California v. Texas on November 10, a case that challenges the constitutionality of the law.
If the ACA is declared unconstitutional, many Americans will lose their health insurance. Despite the promises that the Trump administration’s yet-to-be-revealed new healthcare plan will cover all pre-existing conditions and lower healthcare insurance premiums, there is little information on how they will implement this new plan.
While it is not fully clear what this would mean for birth outcomes, evidence from Tennessee suggests that sudden Medicaid disenrollment increases financial distress, cost barriers to care, and avoidable hospital visits.
In contrast, the Biden-Harris campaign promises to protect and strengthen the ACA. The campaign platform pledges to provide Americans with a public health insurance option — such as a form of Medicare, expand coverage and lower insurance premiums via tax credits, and extend premium-free public option coverage to eligible low-income Americans in states that have chosen not to expand Medicaid.
The question is: would strengthening the ACA improve racial disparities in maternal and child health?
On the one hand, the ACA has improved rates of preconception counseling, preconception folic acid use, and preconception or postpartum insurance coverage.
However, there is little evidence that dependent coverage provisions and Medicaid expansions improve birth outcomes such as low birth weight, preterm births, or neonatal intensive care unit admissions. These findings are consistent with those from prior studies examining the initial impacts of the prenatal Medicaid expansions of the 1980s and early 90s on birth outcomes.
Yet, studies examining these outcomes separately by race or ethnicity find that the positive benefits of the ACA Medicaid are almost exclusively concentrated among black mothers, including declines in preterm birth, infant mortality, and maternal mortality. For an exception, see here.
Another important issue is that the in utero effects of public health insurance expansions may not emerge until decades after implementation. Given this, it is plausible that further expanding Medicaid could reduce Black-white disparities in maternal and child health, particularly in Southern states that have chosen not to expand the program.
Finally, should the Biden-Harris administration prevail, it is crucial to monitor the financing and delivery of healthcare to avoid exacerbating maternal and child health disparities.
Both the ACA insurance exchanges and most Medicaid expansions rely on capitated private insurance plans, such as managed care, underscoring the general shift from providing insurance through fee for service options in the U.S. While the intention of managed care is to control healthcare costs, it can have unintended consequences, such as worsened prenatal care use and birth outcomes.
Findings from Texas show that the implementation of managed care improves preterm birth and infant mortality among Hispanic infants but worsens these outcomes among Black infants.
There is suggestive, though not definitive, evidence in the Texas case that insurance companies may have targeted women with less complicated and costly births, such as Hispanic mothers, to control costs. Because of this, states must consider whether managed care organizations have incentives to engage in risk selection when negotiating contracts.