741: The impact of Medicaid expansion on outcomes in women with pregestational diabetes

Abstract

Pregnancy outcomes for women with diabetes mellitus (DM) are improved by preconception care, and access to preconception care is enhanced by insurance coverage. We therefore sought to determine whether expanded access to care through Medicaid after enactment of the Affordable Care Act was associated with improved birth outcomes in women with pregestational DM. This is a population-based retrospective cohort study using National Vital Statistics data. All women covered by Medicaid who delivered singleton gestations and had pregestational DM coded on the birth certificate in states using the 2003 birth certificate revision were included. We classified states as “expanded” if they implemented expansion programs in 2014. We compared maternal and neonatal outcomes in 2013 (before policy changes) and 2015 (1 year after Medicaid expansion was enacted) using a difference-in-differences approach to account for secular trends in outcomes unrelated to Medicaid expansion. We then constructed a multilevel model to investigate the association of Medicaid expansion with outcomes adjusted for age, race, education, parity, and clustering by state. Of 27,113 women who delivered during the study period, 12,795 (47.2%) were in states that expanded Medicaid. First trimester prenatal care entry was more common in 2015 than in 2013 in both expanded states (+4.6%) and non-expanded states (+3.4%), and was not associated with Medicaid expansion (adjusted odds ratio (aOR) 1.09, 95% CI 0.94-1.27). Primary cesarean delivery was less common in 2015 than in 2013 in both expanded (- 0.8%) and non-expanded states (-0.9%), and these differences were not associated with Medicaid expansion (aOR 1.00, 95% CI 0.89-1.14). Although fewer infants were large-for-gestational age in 2015 than in 2013 in both expanded (-1.0%) and non-expanded states (-0.6%), frequency of neonatal morbidity (NICU admission at term, NICU admission overall, and >6 hours of respiratory support) increased over the study period; these changes were all independent of Medicaid expansion. (Table) Medicaid expansion was not associated with differences in early prenatal care, maternal or neonatal outcomes among women with pregestational DM. Access to preconception care is necessary, but insurance access alone may not be sufficient to improve outcomes in this population.