Teenage Pregnancy Insurance Access,Outcome Disparities,and State Medicaid Expansion

Abstract

Teenagers who give birth in the United States have known risks for morbidity. This population often has limited access to care. This study examined the association of state Medicaid expansion with insurance attainment, adequate prenatal care, maternal hypertension, and maternal diabetes, and investigated racial and ethnic disparities, using a cross-sectional 2019 national database. Multivariable logistic regression analyses were performed. Teenagers in Medicaid expansion states were more likely to acquire insurance during pregnancy (P < .001). State Medicaid expansion status was not associated with prenatal care adequacy, maternal hypertension, or diabetes, but significant racial/ethnic disparities existed. Compared with non-Hispanic white teenagers, non-Hispanic black teenagers had increased odds of inadequate prenatal care (odds ratio [OR] = 1.77, 95% confidence interval [CI] = 1.02, 3.05) and hypertension (OR = 2.18, 95% CI = 1.23, 3.86), and Hispanic teenagers had increased odds of diabetes (OR = 3.72, 95% CI = 1.05, 13.13). Focused efforts to improve perinatal health among pregnant teenagers are important for this high-risk group.

Keywords

teen pregnancy maternal hypertension maternal diabetes health policy teen health

Introduction

Teenage pregnancy accounted for 6% of total births from 2016 to 2019 in the United States¹ and occurs at higher rates than peer-income countries.² Compared with pregnant adults, pregnant teenagers are at higher risk for inadequate prenatal care,³ maternal anemia,^4,5 mental and behavioral health disorders,⁴ hypertensive disorders,^1,5 and severe morbidity in pregnancy, including admission to intensive care units, eclampsia, uterine damage, and unplanned hysterectomy.⁶ These differences are hypothesized to be in part due to biological immaturity although these physiological mechanisms are not fully understood.⁵ There are also racial and ethnic disparities in US teenage pregnancy rates and outcomes, rooted in structural racism that has impacted reproductive health care access and quality,⁷ with non-Hispanic black teenagers experiencing the highest rates of severe maternal morbidity.⁶

About three quarters of teenage pregnancies are covered by public insurance.⁸ State Medicaid expansion, first implemented in 2014 through the Affordable Care Act (ACA), has changed the landscape of healthcare in the United Kingdom. In 2019, 33 states had expanded Medicaid. Medicaid expansion has been associated with increased insurance access and improved prenatal care receipt in pregnant individuals.⁹ Variable evidence exists on the effects of Medicaid expansion on adult maternal outcomes more broadly.^9,10

While children <19 years old from low-income households should be covered by the Children’s Health Insurance Program (CHIP), studies have found that Medicaid expansion still led to increased insurance coverage for these children. Even though Medicaid expansion was not focused on expanding insurance coverage to children, this increased coverage is thought to be due in part to the “welcome mat” effect from increasing Medicaid enrollment for adults in the household.^11-13 Therefore, pregnant teenagers represent a unique group, who may have increased theoretical access to insurance at or younger than 18 years old. However, they are still often underinsured and then must also navigate insurance access as adults at the age of 19 years.^12-14

Less is understood for pregnant teenagers about any associations with living in Medicaid expansion compared with non-expansion states on maternal insurance and outcomes, including any health-related disparities.¹⁵ The objectives of this study were to examine, among pregnant teenagers 19 years old or younger, the association between state Medicaid expansion status and the following: (1) attainment of insurance during pregnancy; (2) maternal outcomes of (a) adequate prenatal care, (b) hypertension, and (c) diabetes related to pregnancy; and (3) impacts on maternal outcomes by race and ethnicity. We hypothesized that Medicaid expansion would lead to improved insurance attainment for pregnant teenagers. Given known linkages of Medicaid expansion with insurance¹⁶ and prenatal care access in adults,⁹ we hypothesized that increased monitoring and anticipatory guidance would decrease rates of hypertension and diabetes among pregnant teenagers and could potentially mitigate disparities in these diagnoses.

Materials and Methods

This was a cross-sectional analysis of retrospective population-based data from the 2019 Pregnancy Risk Assessment Monitoring System (PRAMS), a national perinatal surveillance system established by the Centers for Disease Control and Prevention and administered by state departments of health.¹⁷ The PRAMS monitors selected self-reported maternal behaviors and experiences among women who delivered a live-born infant in the prior 2 to 4 months, with a maximum allowable recall of 9 months postpartum. Thus, the PRAMS database does not include maternal mortality data. Using standardized data collection methods, monthly stratified samples are selected from birth certificates with mailed questionnaires and telephone follow-up for nonrespondents. Survey data are linked to birth certificate data and weighted for sample design, nonresponse, and noncoverage. Statewide response rates ranged from 38% to 80%, with a threshold of 50% in 2019 for data to be released. Texas did not participate, and 7 states were under the threshold (Arizona, Indiana, Nevada, Ohio, Oklahoma, South Carolina, and West Virginia). This study was deemed exempt by our Institutional Review Board as not human subjects’ research.

All respondents 19 years or younger were included in the study. Participants were excluded if the following data were reported as missing or unknown: maternal race/ethnicity, pre-pregnancy or prenatal insurance, weeks to first prenatal visit, adequacy of prenatal care utilization (APNCU) score, maternal hypertension, maternal diabetes, infant gestational age, or infant birth weight. Respondents were excluded if the infant was reported as “not alive,” “don’t know,” or “missing” (Figure 1). Those excluded were compared with included participants to determine whether any bias existed.

State Medicaid expansion was the primary exposure. The ACA gave states the option to expand Medicaid to cover individuals up to 138% of the federal poverty level (FPL), with enhanced federal matching for expansion states. Twenty-four states and the District of Columbia (DC) initially expanded Medicaid, effective January 1, 2014. By the year of our study, 2019, a total of 33 states and DC expanded Medicaid. For our study, any state that had not expanded Medicaid by January 2019 was considered a “non-expansion” state.¹⁸ In Virginia and Maine (expanded in January 2019), a pregnancy was considered “Medicaid expansion” if the birth was in or after May 2019, representing approximately half of the pregnancy occurring after expansion.

The primary outcomes included (1) prenatal insurance status, defined as self-reported insurance type for the question “During your most recent pregnancy, what kind of health insurance did you have for your prenatal care?” with options for public, private, other, or none and (2) maternal outcomes of pregnancy, including: (a) receipt of adequate prenatal care defined by the APNCU index, calculating adequate prenatal care based on the timing of initiation of prenatal care (in weeks after pregnancy begins) and percent of prenatal care visits attended, based on the number recommended by the American College of Obstetricians and Gynecologists, calculating a final score categorized to adequate or inadequate;¹⁹ (b) maternal hypertension; and (c) maternal diabetes.

All analyses were conducted within the context of the survey design characteristics of PRAMS. We specified the primary sampling units, sampling weights, and the stratum identifiers as implemented in STATA’s svyset command, allowing for the calculation of representative estimates. Descriptive frequencies were calculated using raw numerical value, weighted population number, and weighted frequency (displayed as a percentage) for maternal demographic characteristics. We then stratified by Medicaid expansion status for the state in which the mother gave birth. We used the χ² statistic to compare states with versus without Medicaid expansion on pre-pregnancy and prenatal insurance status. We conducted a sub-analysis of mothers 18 to 19 years as those 19 years old are ineligible for CHIP; however, we were unable to isolate 19-year-old individuals for this analysis due to PRAMS-specific age groupings. We conducted univariable analyses for each of the outcomes stratified by the Medicaid expansion status of the state in which the mother gave birth, using the χ² statistic.

We then performed multivariable logistic regression modeling, reporting odds ratios (ORs) and 95% confidence intervals (CIs) to test the association between state Medicaid expansion status and maternal outcomes (adequacy of prenatal care, maternal hypertension, and maternal diabetes). We adjusted for the following maternal covariates: race and ethnicity, pre-pregnancy insurance status, prenatal insurance status, prenatal WIC (Special Supplemental Nutrition Program for Women, Infants, and Children) participation, educational status, and language. Finally, to examine whether state Medicaid expansion status differentially impacted maternal outcomes by race and ethnicity, we re-estimated the model while creating an interaction term between race and Medicaid expansion. We calculated the variance inflation factor (VIF) for each covariate to evaluate for collinearity; values greater than 10 were considered evidence for collinearity. Statistical analyses were conducted in STATA version 16.0 (StataCorp, College Station, Texas).²⁰

Results

A total of 1416 maternal-infant dyads with mothers 19 years or younger were included in the study cohort, corresponding to a weighted sample of 73 910 dyads (Figure 1). When comparing states by Medicaid expansion status, there were higher proportions of non-Hispanic black (23%) and non-Hispanic white (49%) mothers in non-expansion states, and higher proportions of Hispanic (30%) mothers in Medicaid expansion states (Table 1). Teenagers in Medicaid expansion states had higher rates of pre-pregnancy public insurance (87%) than those in non-expansion states (72%). During the prenatal period, most pregnant teenagers had public insurance in both Medicaid non-expansion (77%) and expansion states (74%) (Table 1). There were statistically significant demographic differences between teenagers excluded for missing data and those included in the study sample, with higher percentages of non-Hispanic Black (31% vs 21% included; P = .02) and less than high school education status (54% vs 47% included; P = .02).

Table 1.

Demographic Characteristics of Teenage Mothers, by State-Level Medicaid Expansion Status, 2019 (N = 73 910).

Demographic characteristic	No Medicaid expansion		Medicaid expansion^a
Demographic characteristic	Survey respondentsn = 571n	Population estimaten = 35 777n (%)	Survey respondentsn = 845n	Population estimaten = 38 133n (%)
Race/ethnicity
Non-Hispanic white	218	17 442 (49)	216	16 216 (43)
Non-Hispanic black	162	8220 (23)	198	7218 (19)
Hispanic	116	8287 (23)	259	11 340 (30)
American Indian/Alaska Native	43	445 (1)	71	458 (1)
Other/multiple races^b	32	1383 (4)	101	2900 (8)
Census region
Northeast	–^c	–	142	8317 (22)
Midwest	226	6998 (20)	193	11 450 (30)
South	277	27 579 (77)	228	10 650 (28)
West	65	1167 (3)	282	7715 (20)
Insurance (pre-pregnancy)
Private	189	10 302 (29)	244	10 538 (28)
Public	261	15 354 (43)	471	22 436 (59)
Other	–	–	30	1114 (3)
None	106	9402 (26)	100	4043 (11)
Insurance for prenatal care
Private	123	5411 (15)	175	8118 (21)
Public	417	27 679 (77)	621	28 050 (74)
Other	–	–	36	1676 (4)
None	–	–	–	–
Participation in WIC
No	161	10 174 (29)	221	10 838 (29)
Yes	403	25 365 (71)	610	26 433 (71)
Educational status
Less than high school	267	16 554 (46)	406	17 997 (47)
High school/GED	227	15 212 (43)	332	15 650 (41)
At least some college	75	3965 (11)	103	4351 (11)
Language
English	535	32 807 (92)	773	34 752 (91)
Spanish	36	2970 (8)	73	3381 (9)

In 2019, the 33 Medicaid expansion states were Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Hawaii, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Montana, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Dakota, Ohio, Oregon, Pennsylvania, Rhode Island, Vermont, Virginia, Washington, and West Virginia.

The race category of “Other/Multiple Races” includes the following classifications due to low number of subjects: other Asian, Filipino, other non-white, mixed race.

Suppressed cell due to low sample size (<30 individuals).

Those in non-expansion states compared with Medicaid expansion states had higher rates of being uninsured, both during pre-pregnancy and prenatal periods. Among teenagers in the pre-pregnancy period, 26% were uninsured in non-expansion compared with 11% in Medicaid expansion states (P < .001). In the prenatal period, for pregnant teenagers in non-expansion states, 5% were uninsured (population estimate 1842) compared with 1% in Medicaid expansion states (population estimate 288) (P = .005) (Table 2). In a sub-analysis stratifying age groups of teenagers those 18 to 19 years old, who comprised most of the study sample (74%), had similar percentages of being uninsured to those ≤17 years old between the non-expansion and expansion states (Supplemental Table 1). Among all teenagers who were uninsured pre-pregnancy (population estimate 13 446), 85% gained insurance during pregnancy, but 15% remained uninsured (population estimate 2001). The majority of those gaining insurance (94%) obtained public insurance. Teenagers living in Medicaid expansion states were significantly more likely to acquire insurance during pregnancy than those living in non-expansion states (92% vs 86%, respectively, P = .006). Among teenagers who remained uninsured during pregnancy, 91% were of Hispanic ethnicity and 63% reported their preferred language was Spanish. Among those who did acquire insurance during pregnancy, the largest proportion was also Hispanic (60%), followed by non-Hispanic white teenagers (32%).

Table 2.

Teenage Outcomes Stratified by State-Level Medicaid Expansion Status, 2019.

Outcome	No Medicaid expansion		Medicaid expansion^a		χ², P value
Outcome	Survey respondentsn = 571n	Population estimaten = 35 777n (%)	Survey respondentsn = 845n	Population estimaten = 38 133n (%)	χ², P value
Prenatal care (APNCU)					.95
Inadequate	132	8673 (24)	197	8436 (22)
Intermediate	59	3617 (10)	108	3735 (10)
Adequate	191	13 053 (36)	303	14 137 (37)
Adequate plus	189	10 433 (29)	237	11 824 (31)
Prenatal care (weeks to first visit)					.29
≤8 weeks	301	17 876 (50)	415	18 590 (49)
9-13 weeks	161	9560 (27)	277	12 483 (33)
≥14 weeks	109	8341 (23)	153	7059 (19)
Maternal hypertension	118	5846 (16)	144	4707 (12)	.18
Maternal diabetes	–^b	–	34	1402 (4)	.46
Maternal hypertension and/or diabetes	128	6576 (18)	167	5884 (15)	.36

In 2019, the 33 Medicaid expansion states included Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Hawaii, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Montana, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Dakota, Ohio, Oregon, Pennsylvania, Rhode Island, Vermont, Virginia, Washington, and West Virginia.

Suppressed cell due to low sample size (<30 individuals).

For the outcome of adequate prenatal care, there was no difference in prevalence between pregnant teenagers in Medicaid expansion versus non-expansion states (68% vs 67%, P = .95). Hypertension was present in 262 of 1416 individuals, corresponding to a population estimate of 14.2% (10 553/73 910). Diabetes was present in 54 of 1416 individuals, corresponding to a population estimate of 3.1% (2318/73 910). There was also no difference between groups in prevalence of hypertension or diabetes (Table 2). In multivariable analyses, Medicaid expansion was not associated with the maternal outcomes of inadequate prenatal care, maternal hypertension, or maternal diabetes (Table 3).

Table 3.

Multivariable Analyses for the Association Between Medicaid Expansion and Health Outcomes Among Teenage Birthing Individuals.

Independent variable	Inadequate prenatal care^a aOR (95% CI)	Maternal hypertensionaOR (95% CI)	Maternal diabetesaOR (95% CI)
Medicaid expansion state^b	0.80 (0.50, 1.28)	0.73 (0.46, 1.16)	1.25 (0.31, 5.08)
Race/ethnicity
Non-Hispanic white	Referent	Referent	Referent
Non-Hispanic black	1.77 (1.02, 3.05)	2.18 (1.23, 3.86)	1.64 (0.48, 5.61)
Hispanic	1.75 (0.90, 3.41)	0.87 (0.44, 1.72)	3.72 (1.05, 13.13)
American Indian/Alaska Native	2.49 (0.93, 6.69)	1.23 (0.50, 3.05)	3.38 (0.74, 15.46)
Other/multiple races^c	1.90 (0.62, 5.81)	0.91 (0.33, 2.52)	1.04 (0.26, 4.19)
Insurance (pre-pregnancy)
Private	Referent	Referent	Referent
Public	2.06 (0.98, 4.34)	0.69 (0.33, 1.45)	1.88 (0.42, 8.40)
Other	2.98 (0.61, 14.53)	0.93 (0.13, 6.47)	2.59 (0.43, 15.67)
None	2.66 (1.08, 6.55)	0.51 (0.17, 1.57)	4.30 (0.68, 27.41)
Insurance for prenatal care
Private	Referent	Referent	Referent
Public	0.58 (0.26, 1.28)	1.16 (0.56, 2.39)	0.17 (0.04, 0.72)
Other	1.49 (0.34, 6.65)	0.74 (0.10, 5.70)	0.06 (0.01, 0.39)
None	0.27 (0.05, 1.43)	3.26 (0.45, 23.77)	0.06 (0.00, 0.79)
Participation in WIC
No	Referent	Referent	Referent
Yes	0.71 (0.43, 1.15)	0.92 (0.54, 1.56)	2.30 (0.99, 5.39)
Educational status
Less than high school	Referent	Referent	Referent
High school/GED	0.63 (0.39, 1.02)	1.30 (0.79, 2.13)	0.86 (0.34, 2.17)
At least some college	0.20 (0.08, 0.48)	1.02 (0.43, 2.39)	0.80 (0.19, 3.46)
Language
English	Referent	Referent	Referent
Spanish	1.99 (0.88, 4.55)	0.25 (0.05, 1.22)	0.23 (0.03, 1.67)

Bolded values represent statistical significance with 95% confidence interval not crossing 1.

Inadequate prenatal care as classified by the APNCU score.

The race category of “Other/Multiple Races” includes the following classifications due to low number of subjects: other Asian, Filipino, other non-white, mixed race.

However, multivariable models demonstrated racial and ethnic disparities even after controlling for other maternal characteristics and state Medicaid expansion status. Compared with non-Hispanic white teenagers, non-Hispanic black teenagers had higher odds of inadequate prenatal care (OR = 1.77, 95% CI = 1.02, 3.05) and maternal hypertension (OR = 2.18, 95% CI = 1.23, 3.86). Hispanic compared with non-Hispanic white teenagers had higher odds of maternal diabetes (OR = 3.72, 95% CI = 1.05, 13.13). Lack of pre-pregnancy insurance was associated with increased odds of inadequate prenatal care (OR = 2.66, 95% CI = 1.08, 6.55), but not maternal hypertension or diabetes. Finally, a higher level of education, defined as “at least some college education,” was associated with lower odds of inadequate prenatal care (OR = 0.20, 95% CI = 0.08, 0.48) (Table 3). For each outcome, the interaction factor of race/ethnicity by Medicaid expansion was not significant, with P values > .05. The VIF values for covariates across all models ranged from 1.01 to 3.77, indicating that collinearity was not a concern.

Discussion

In our study focusing on maternal health insurance and clinical outcomes for teenagers, living in a Medicaid expansion compared with non-expansion state was associated with increased insurance coverage during pregnancy. No differences were seen between Medicaid expansion and non-expansion states for the maternal outcomes of inadequate prenatal care, maternal hypertension, or maternal diabetes. Despite increased insurance access during pregnancy in teenagers in Medicaid expansion states, there remained disparities by race and ethnicity for these maternal outcomes. These findings are important and novel as previous studies on the association of Medicaid expansion on these outcomes in pregnancy have focused on the overall population of pregnant individuals, and not specifically on teenagers.

Lack of insurance remains an important issue for pregnant teenagers, despite the availability of CHIP for individuals ≤18 years old from low-income families, and Medicaid for low-income individuals 19 years and older.²¹ Medicaid reform in the 1990s increased prenatal insurance access by covering pregnant low-income women and teenagers.²² The 2014 ACA gave states the option to expand Medicaid to increase coverage for low-income individuals; however, there are limited studies about these expansion effects among pregnant teenagers. Our study demonstrated that for teenagers who are uninsured pre-pregnancy, living in a Medicaid expansion, compared with non-expansion, state, was associated with increased likelihood of obtaining insurance during pregnancy for all age groups. This is consistent with studies among pregnant adults, especially for those of lower income.^9,23 Our findings are also consistent with studies demonstrating a “welcome mat” effect of increased insurance coverage among children in low-income families living in Medicaid expansion states.^11-13

A much larger percentage of pregnant teenagers (74%-77%), in both expansion and non-expansion states, were covered by public insurance, compared with 43% in the overall pregnant population.²⁴ This suggests that Medicaid and CHIP play a large role in insurance access for pregnant teenagers. We hypothesize that having pre-pregnancy insurance is an important factor in having prenatal insurance by decreasing barriers to obtaining insurance in the early months of pregnancy, despite increased eligibility for public insurance by FPL during pregnancy.²⁵

Hispanic children ≤18 years old have rates of uninsurance 1.5 times the national average.²⁶ Our study also demonstrated higher proportions of uninsured pregnant teenagers among those of Hispanic ethnicity. These results are consistent with decreasing insurance coverage for individuals of Hispanic ethnicity during the same time period.²⁷ Reasons for this may include immigration-related fears, the political climate during the contemporary era,²⁷ or language barriers that limit health literacy and ability to acquire insurance.

State Medicaid expansion status was not associated with reductions in inadequate prenatal care among our study population. One systematic review of pregnant individuals found mixed evidence on the impact of the ACA Medicaid expansion on prenatal care.⁹ Furthermore, there is state-level variability in women’s reproductive care quality that may further impact access to high-quality prenatal care.²⁸ Significant racial disparities were seen in our study, with non-Hispanic black compared with non-Hispanic white teenagers having higher odds of inadequate prenatal care. Barriers to care include structural factors including availability of appointments, access to transportation, and financial challenges for young women less than 24 years old.²⁹ Reported experiences of discrimination and dismissal, both related to maternal race and age, suggest larger systemic issues are likely contributing to these disparities.³⁰ One protective factor in our study for having adequate prenatal care was education level, specifically some college education. This is consistent with prior research, which found higher educational attainment was positively associated with improved infant outcomes among teen mothers.³¹

While there were no differences in Medicaid expansion versus non-expansion states in the odds of hypertension and diabetes during pregnancy, disparities in maternal outcomes by race and ethnicity were present, consistent with adult studies.³² In pregnant teenagers, this increased prevalence of maternal morbidity is particularly concerning as it places them at risk for severe morbidity and mortality during and after pregnancy, as well as potential lifelong health complications.³³ These disparities in maternal outcomes are due to a complex interaction of factors, including in part structural racism and inequitable care. Economic inequality, educational disparity, decreased access to health care, historical injustices of the medical system, biases in care, as well as resultant epigenetic disruptions have been hypothesized to influence these disparities.^34,35

There are policy and programmatic implications from this study to improve maternal and infant outcomes. First, as uninsured pregnant teenagers in Medicaid expansion compared with non-expansion states have higher rates of insurance acquisition, efforts should continue to expand Medicaid.¹⁸ Second, among persistently uninsured pregnant teenagers, Hispanic teenagers and those whose preferred language is Spanish were disproportionately impacted. Focused outreach to these communities will be important to increase insurance coverage, including programs directly addressing community concerns related to punitive immigration laws.³⁶ In addition, while interpreter use is required for Medicaid programs, institutional implementation and availability are varied.³⁷ To improve knowledge dissemination and enrollment for insurance for prenatal care, it will be essential to increase translation of written materials and verbal interpretation.³⁸ Third, with the well-described disparities in maternal hypertension and diabetes in all ages, there must be continued efforts to better understand causes and effective interventions for pregnant teenagers specifically.³⁹ While maternal health data on severe maternal morbidity and other perinatal health conditions are available, there is growing recognition of the critical need to de-aggregate these data by race/ethnicity,⁴⁰ and this study demonstrates the need to stratify the data to focus on teenagers from marginalized populations. Data-informed and community-engaged efforts will be needed to address the adverse health outcomes arising from systemic racism and resultant social and economic inequities.

Limitations

Our study has several limitations. First, 7 states were not included in the database for 2019 due to inadequate data. In addition, Texas, a non-expansion state with a large teenage population, did not contribute data to PRAMS. Surveys were not offered in all languages, limiting responses from those with other preferred languages, and there were differences by race and educational status among those excluded for missing data. The maternal morbidities (hypertension and diabetes) included in our analysis would likely be identified during prenatal care visits, and thus rates of these morbidities may be underdiagnosed among those with inadequate or no prenatal care. Furthermore, there were limited data on other outcomes that may be responsive to health insurance access. There was limited sample size for pregnant teenagers with maternal diabetes; however, given the sampling methodology, comparative analyses were adequately performed. Due to the specifications of the PRAMS database, we were unable to isolate only the birthing individuals who were 19 years old, who may have the most benefit from Medicaid expansion as they are not eligible for CHIP. As this is an ecologic study, we cannot report causation, but only associations between exposure and outcomes. Finally, while the sampling method of PRAMS is meant to appropriately reflect the United States, it may not be generalizable for changes in health policy that have occurred in the years since this study was performed, namely the pandemic.

Conclusion

Teenage pregnancy remains a pressing issue in the United States with persistent disparities in maternal outcomes by race and ethnicity. Rates of uninsurance were higher among pregnant teenagers in non-expansion compared with Medicaid expansion states. Despite increased insurance access for pregnant teenagers in these states, Medicaid expansion was not associated with improved maternal outcomes. Future research should evaluate other modifiers for access to prenatal healthcare for teenage birthing individuals, who remain a high-risk group. Given the long-term health implications of maternal hypertension and diabetes even after pregnancy, interventions earlier in the lifespan can have important implications for the long-term health of these young birthing individuals.

Author Contributions

KED: contributed to conceptualization, methodology, drafting the manuscript, and critically revising the manuscript.

SSH: contributed to methodology, supervision, and critically revising the manuscript.

MCM: contributed to methodology, formal analysis, and critically revising the manuscript.

LKL: contributed to methodology, formal analysis, critically revising the manuscript, funding acquisition, and supervision. All authors gave final approval and agree to be accountable for all aspects of work.

Supplemental Material

sj-docx-1-cpj-10.1177_00099228251383841 – Supplemental material for Teenage Pregnancy Insurance Access, Outcome Disparities, and State Medicaid Expansion

Supplemental material, sj-docx-1-cpj-10.1177_00099228251383841 for Teenage Pregnancy Insurance Access, Outcome Disparities, and State Medicaid Expansion by Katherine E. Douglas, Sunah S. Hwang, Michael C. Monuteaux and Lois K. Lee in Clinical Pediatrics

Footnotes

Acknowledgements

The authors thank the PRAMS Working Group for use of the PRAMS data set for this study.

ORCID iD

Katherine E. Douglas

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Lovejoy Resident Research and Educational Grant at Boston Children’s Hospital for funding for statistical analysis. The funders had no role in study design; in the collection, analysis and interpretation of data; in the writing of the report; nor in the decision to submit the article for publication.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The data are available via the CDC’s PRAMS website upon application and approval.

Supplemental Material

Supplemental material for this article is available online.

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