What Does the Recent Literature Say About Medicaid Expansion?: Impacts on Sexual and Reproductive Health

A substantial body of research has investigated effects of the Affordable Care Act (ACA) Medicaid expansion, adopted by all but 10 states as of June 2023. This brief updates prior KFF literature reviews by summarizing 40 studies published between April 2021 and June 2023 on the impacts of Medicaid expansion on a range of sexual and reproductive health outcomes.

Medicaid Funding and Coverage Overview

Medicaid is the largest source of public funding for family planning services—which are a mandatory benefit within the program—and finances 4 in 10 births in the United States, as well as provides prenatal and postpartum coverage. Federal law requires all states, including those that have not expanded Medicaid, to provide Medicaid coverage to pregnant individuals with incomes up to at least 138% of the federal poverty level (FPL). However, coverage options for the pre-pregnancy and postpartum periods vary across states and are more limited in non-expansion states. Nationwide, nearly 900,000 women fall into the coverage gap in non-expansion states.

Insurance Coverage Before, During, and After Pregnancy

Prior studies overwhelmingly found that expansion increased postpartum coverage rates, as well as coverage prior to and during pregnancy. Although the American Rescue Plan Act of 2021 created a new option to expand postpartum coverage to 12 months via a State Plan Amendment, current federal statute requires that pregnancy-related Medicaid coverage continue through just 60 days. Earlier research indicates that ACA Medicaid expansion has decreased coverage loss after this 60-day period ends: all prior studies that consider rates of insurance coverage after pregnancy find that expansion significantly increased postpartum coverage. Most recent studies continue to find that expansion is associated with coverage gains in the pre-pregnancy, pregnancy, and postpartum periods. All recent studies that consider the impact of expansion on insurance coverage prior to conception and at birth find coverage gains. One study considered Medicaid coverage post-abortion in Oregon and found a significant increase, as well as significant declines in lapses in enrollment.

Key Research Findings and Topic Areas

Included study findings fall into four topic areas:

• health insurance coverage before, during, and after pregnancy;
• maternal and infant health access, utilization, and outcomes;
• family planning; and
• HIV care and prevention.

Consistent with prior research, recent studies identify positive effects of Medicaid expansion on coverage rates before, during, and after pregnancy; access to prenatal and postpartum care; birth and postpartum outcomes; use of the most effective contraceptive methods; and HIV screening and outcomes.

Data Summary and Impact Statistics

• States Not Expanded (as of June 2023): 10 states
• Women in the Coverage Gap: Nearly 900,000
• Medicaid Share of U.S. Births: 4 in 10
• Studies Summarized: 40 studies (April 2021 to June 2023)
• Federal Poverty Level (FPL) Income Requirement: Up to at least 138%