Pandemic Medicaid protections cut postpartum uninsurance for Black mothers - but did not close the racial gap

In 2019, roughly one in six Black women in states that had not expanded Medicaid under the Affordable Care Act were uninsured after giving birth. Among White women in those same states, the rate was about one in nine. Then the pandemic arrived, and with it a temporary policy that would inadvertently create one of the largest natural experiments in postpartum coverage the U.S. has seen.

The COVID-19 continuous Medicaid coverage provision - which prevented states from disenrolling beneficiaries during the public health emergency - kept new mothers on Medicaid who would otherwise have lost coverage shortly after delivery. A new study from Columbia University's Mailman School of Public Health, published in the American Journal of Preventive Medicine, now quantifies what that policy accomplished and where it fell short.

A 5-point swing in non-expansion states

The researchers, led by Teresa Janevic, analyzed American Community Survey data covering 157,016 non-Hispanic Black and non-Hispanic White women who had given birth in the previous 12 months, across all 50 states and D.C., from 2016 through 2023.

The headline finding: postpartum uninsurance among Black women fell significantly in non-expansion states during the continuous coverage period. By 2023, postpartum uninsurance among Black women had declined 5 percentage points more in non-expansion states than in expansion states - a meaningful shift driven largely by increased Medicaid enrollment. Among Black women in non-expansion states, postpartum Medicaid coverage rose from 38% in 2019 to 42% in 2023, peaking at 45% in 2021.

The pattern for White women was different in an instructive way. Their postpartum uninsurance also dropped more in non-expansion states, but the mechanism was primarily gains in private insurance (accounting for 69% of the improvement) rather than Medicaid (20%). The two groups were both helped by the policy, but through different channels - a reflection of the different insurance landscapes they navigate.

The gap that did not close

Here is the finding that complicates the good news: despite meaningful improvements for Black women, the Black-White disparity in postpartum uninsurance remained unchanged. Both groups benefited from the continuous coverage policy, so the absolute gap between them held steady.

This matters because the postpartum period is not just a window of insurance coverage - it is a window of medical vulnerability. In 2022, Black women had twice the rate of pregnancy-related death within 42 days of delivery compared to White women, and were more than four times as likely to die from pregnancy-related causes up to 12 months postpartum. Beyond mortality, the disparities extend to severe maternal morbidity, postpartum depression, hospital readmissions, and emergency department visits.

Insurance coverage alone cannot account for all of these disparities - structural racism, provider bias, and differential access to quality care all play roles. But coverage is a prerequisite for access, and gaps in coverage are most consequential precisely when medical needs are most acute.

The policy landscape now

The continuous coverage provision was a pandemic emergency measure that has since ended. But its effects helped motivate a more permanent policy shift: under the American Rescue Plan Act, 49 states have now enacted laws extending Medicaid postpartum coverage to 12 months, making it one of the largest policy responses to the U.S. maternal health crisis.

Before the pandemic, the coverage gap was starkest in non-expansion states. In 2019, 16.5% of Black women and 11% of White women in non-expansion states were uninsured postpartum, compared with 6.4% and 5.4% in expansion states. The continuous coverage policy demonstrated that extended Medicaid eligibility could substantially narrow that geographic gap.

Necessary but not sufficient

Janevic framed the findings carefully: postpartum Medicaid extension "plays an important role in improving access to postpartum care" but "is unlikely to be sufficient on its own to address the U.S. Black maternal health crisis." Coverage gets women through the door. What happens on the other side of that door - the quality, timeliness, and cultural competence of care - is a separate set of problems.

The study also carries a warning embedded in its data. Because Black women are disproportionately reliant on Medicaid for pregnancy-related care, any future policies that reduce Medicaid access would hit Black maternal health outcomes hardest. The connection between coverage and survival runs in both directions.