Expanding Care, Entrenching Disparities: Medicaid Expansion and Racial/Ethnic Inequities in Preconception Health

Abstract

The Affordable Care Act’s expansion of Medicaid coverage took effect in 2014, extending eligibility to millions of low-income adults. This paper exploits the cross-state variation in policy implementation to estimate the effects of Medicaid expansion on preconception health among women of reproductive age. Women’s health in the period before pregnancy is a critical research area because it has important implications for maternal and infant health outcomes. While previous studies examine the association between Medicaid expansion and preconception health, evidence on differential effects by race/ethnicity remains notably underexplored in the literature. Using aggregated data from the Behavioral Risk Factor Surveillance System (BRFSS), I estimate Callaway and Sant’Anna and Borusyak et al. staggered-adoption difference-in-differences models, as well as a triple-difference specification specifically for American Indian and Alaska Native women, to examine a range of outcomes relevant to preconception health. These outcomes span measures of access to care, preventive care utilization, mental and physical health status, and health behaviors. I find substantial heterogeneity in effects across both racial/ethnic subgroups and outcome types. While some groups experienced meaningful improvements primarily in access to and utilization of care, others saw more limited or inconsistent gains across outcomes, suggesting that the benefits of Medicaid expansion on preconception health were not evenly distributed across racial/ethnic populations. These findings suggest that expanding insurance coverage is necessary but not sufficient for advancing preconception health equity. Future policy aiming to improve preconception health may consider pairing insurance reform with more targeted interventions designed to address the distinct social determinants of health and access to care for each racial/ethnic population.