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STATISTICAL BRIEF #547:
Insurance Status of Mothers at the Time of Birth, by Demographic Characteristics, 2008-19

February 2023

Jessica Monnet, PhD, and Julie Hudson, PhD

Highlights

The percentage of mothers who were uninsured at the time of birth declined from 10.4% to 5.9%, or by 43.3%, between 2008-2013 and 2014-2019.
The percentage of mothers who were privately covered at the time of birth increased from 55.4% to 60.5%, or by 9.2%, between 2008-2013 and 2014-2019.
There was no significant change in the percentage of mothers with public coverage at time of birth between 2008-2013 and 2014-2019.
When considering age subgroups, declines in the percentage of mothers who were uninsured at the time of birth were observed among women in the following age categories: 13 to 19, 20 to 29, and 30 to 39.
Compared with non-Hispanic White and non-Hispanic Black mothers, Hispanic mothers experienced the largest percentage point decline (9.9 percentage points) in the percentage uninsured at time of birth between 2008-2013 and 2014-2019.
Increases in the percentage of mothers who were privately covered at the time of birth were observed among Hispanic and non-Hispanic Black mothers.
Accounting for educational attainment, declines in the percent of mothers who were uninsured at the time of birth were observed among those whose highest level of schooling was either a high school diploma/GED or a bachelor's degree.
When stratified by the federal poverty level (FPL), the percentage of mothers who were uninsured at the time of birth declined only for women in families with incomes at 0-138% FPL and 251-400% FPL.

Introduction

In 2014, the Affordable Care Act (ACA) increased the accessibility of health insurance by expanding Medicaid eligibility for adults with family incomes up to 138% of the federal poverty level (FPL) and introducing tax credits and cost-sharing for private insurance coverage available through Marketplace exchanges. Prior work observes that, after the introduction of the ACA's Medicaid expansion and Marketplace policies, previously uninsured adults gained insurance coverage in 2014 via Medicaid and Marketplace plans.^1,2,3,4 In contrast, enrollment in employer-sponsored insurance (ESI) declined between 2008 and 2015 in both Medicaid expansion and non-expansion states.⁵ Although most states cover pregnant women through Medicaid or CHIP at higher income levels than the ACA Medicaid expansion to adults, Medicaid pregnancy coverage is temporary and ends 60 days postpartum.^a

This statistical brief looks at the insurance status of mothers at the time of birth, before and after the introduction of the ACA. Specifically, relying on the Full-Year Consolidated files for the Household Component of the Medical Expenditure Panel Survey (MEPS-HC) between 2008 and 2019, we describe the insurance status of mothers by the following demographic characteristics: age, race/ethnicity, highest level of education, and percent of the federal poverty level. We define the pre-ACA period as 2008 through 2013, and the post-ACA period as 2014 through 2019.

All findings in this statistical brief represent the characteristics of the mother in the month her child was born. Changes reported in the text are statistically significant at the 5% level or higher, unless otherwise noted.

^a As of January 2022, 35 states covered pregnant women at or above 200% of FPL.⁶ As of October 2022, 28 states had extended pregnancy coverage from 60 days postpartum to 12 months postpartum, and 8 states were considering similar extensions. These extensions were not in place for the time period covered in this Statistical Brief.⁷

Findings

Insurance Trends

Figure 1 presents trends for the percentage of birth mothers who were uninsured, who held only public coverage, and who had any private coverage between 2008 and 2019. This figure illustrates two points. First, most birth mothers have private insurance and only a small percentage are uninsured. Second, we observe that the percentage of birth mothers with any private insurance increased, and the percentage who were uninsured decreased after 2013.

Figure 2 shows a similar trend, indicating that the average share of birth mothers who were uninsured declined between our pre-ACA and post-ACA periods. Specifically, uninsured birth mothers declined from 10.4% in 2008-2013 to 5.9% in 2014-2019. This change represents a 4.5 percentage point drop (10.4 - 5.9 = 4.5) and a 43.3% decrease overall after 2013 (i.e., 4.5/10.4 = 0.433 or 43.3%). In contrast, the share of birth mothers who had any private insurance increased by 5.1 percentage points (9.2%). Both figures suggest that the overall share with only public coverage remained relatively constant between 2008 and 2019.

Insurance Status by Demographic Characteristics

The subsequent figures stratify the insurance status of birth mothers by relevant demographic characteristics (i.e., age, race and ethnicity, highest level of education, and percent of the FPL).

Insurance Status by Age

Figure 3 illustrates the distribution of birth mothers' insurance status by the following age groups: 13 to 19, 20 to 29, 30 to 39, and 40 plus. For all age groups, the percentage of uninsured birth mothers declined after 2013. Specifically, the percentage of uninsured birth mothers aged 13 to 19, 20 to 29, and 30 to 39 declined by 6.2 percentage points (71.3%), 5.3 percentage points (43.8%), and 3.1 percentage points (36.9%), respectively. Although these estimates range from 3.1 to 6.2 percentage points, the sizes of these changes are not statistically different from one another. In addition, for birth mothers aged 30-39, public coverage increased by 4.5 percentage points (23.3%), and any private coverage increased by 16.8 percentage points (25.9%) for birth mothers aged 40 plus.

Insurance Status by Race and Ethnicity

Figure 4 presents the distribution of birth mothers' insurance status by race and ethnicity (i.e., Hispanic, non-Hispanic Black, and non-Hispanic white).^b After 2013, the percentage of uninsured birth mothers declined for nearly all race and ethnicity groups. Specifically, the percentage of uninsured Hispanic, non-Hispanic Black, and non-Hispanic White birth mothers declined by 9.9 percentage points (44.8%), 4.6 percentage points (57.5%), and 2.8 percentage points (41.2%), respectively. These changes are statistically different from one another at the five-percent level. Moreover, we find that private coverage increased by 10.1 percentage points (32.0%) for Hispanic birth mothers and by 7.9 percentage points (25.9%) for Non-Hispanic Black birth mothers. These changes are not statistically different from one another.

Insurance Status by Highest Level of Education

Figure 5 presents the distribution of birth mothers' insurance status by mothers' highest level of education (i.e., less than a high school (HS) diploma or GED, a HS diploma or GED, some college, bachelor's degree (BA), and more than a BA). We find that, after 2013, the percentage of birth mothers with a HS diploma or GED that were uninsured declined by 5.0 percentage points (43.9%). Similarly, the percentage of birth mothers with a BA that were uninsured decreased by 6.5 percentage points (73.0%).

Insurance Status by Family Income

Last, Figure 6 presents the distribution of birth mothers' insurance status by family income as a percent of the federal poverty level (i.e., 0-138%, 139-250%, 251-400%, and > 400%). After 2013, the percentage of birth mothers at 0-138% of the FPL who were uninsured declined by 7.4 percentage points (47.1%). We also find that the percentage of birth mothers at 251-400% of the FPL who were uninsured declined by 6.1 percentage points (71.8%).

^b Due to our precision requirements with respect to reporting, we cannot report individual statistics for birth mothers of Asian, Native American, Alaskan Native, Native Hawaiian, or Pacific Islander descent, and birth mothers that have indicated multiple races (i.e., the underlying sample sizes are too small).

Data Source

The estimates presented in this statistical brief were generated from analysis conducted by MEPS staff using the following public use files: HC-120, HC-121, HC-128, HC-129, HC-137, HC-138, HC-146, HC-147, HC-154, HC-155, HC-162, HC-163, HC-170, HC-171, HC-180, HC-181, HC-190, HC-192, HC-199, HC-201, HC-207, HC-209, HC-214, and HC-216.

Definitions

Birth Mothers

We define birth mothers as women in the Medical Expenditure Panel Survey Full Year Consolidated Data File who are identified as being the mother to an infant child living in the MEPS household. Specifically, we focus on women between 2008 and 2019 whose infant child resides in their MEPS-HC household and use the child's birthdate to identify the month of birth. This analysis does not include mothers whose child resides in a different household or mothers who had stillbirths. In addition, because MEPS does not distinguish between adoptive and biological parental relationships, our sample may include some adoptive mothers. However, using reported medical conditions codes, 91% of our sample mothers reported a pregnancy or birth-related visit within 9 months of the child's birthday.

Pre-/Post-ACA

Although the ACA was passed in 2010, 2014 marks the year in which Marketplace insurance exchanges and associated economic support policies were implemented. Furthermore, with only a few exceptions, 2014 is the year in which states adopted the Medicaid expansion to adults.⁸ Our choice to break the pre-/post-ACA periods at 2013/2014 will not allow researchers to address the impact of ACA policies adopted earlier, such as extending dependent coverage eligibility to all children up to age 25.

Uninsured

Uninsured is defined as birth mothers who are not covered by TRICARE (Armed Forces-related coverage), Medicare, Medicaid, SCHIP, other public hospital/physician insurance, private hospital/physician insurance (including Medigap plans), or Veterans Administration (VA). IHS is not included as a source of coverage.

Public Insurance Only

Public insurance only is defined as birth mothers for whom the only source of insurance coverage is TRICARE, Medicare, Medicaid, SCHIP, other public hospital/physician programs, or VA. IHS is not included as a public source of coverage.

Any Private Insurance

Any private insurance is defined as birth mothers with at least one source of insurance coverage (hospital/physician) through an employer or union, non-group or other group (i.e., not employment-related), and private insurance through a federally facilitated, state-based, or state partnership exchange or marketplace. The mother may be the primary insurance policy holder or a beneficiary of the primary insurance policy holder.

Age

Age is defined as the birth mother's exact age as of December 31 of the relevant year.

Education

We classified education using information on the highest level of schooling completed or the highest degree received by a person when they entered the MEPS, the number of years of education completed when they entered the MEPS, and interim highest level of education or years of education. The categories included in this statistical brief are: (1) less than a HS diploma or GED, (2) a HS diploma or GED, (3) some college (no BA), (4) a BA, and (5) more than a BA.

Race/Ethnicity

We classified race and ethnicity using information reported for each family member. Specifically, respondents were asked if each family member's race was best described as White, Black, American Indian or Alaska Native, Asian, Native Hawaiian or Pacific Islander, or multiple races. Similarly, respondents were asked if each family member's ethnic background was best described as Mexican, Mexican American or Chicano, Puerto Rican, Cuban or Cuban American, Dominican, Central or South American, other Latin American, other Hispanic/Latino/Spanish origins, or multiple Hispanic groups. All persons whose ethnic background was reported in one of these Hispanic groups, regardless of racial background, were classified as Hispanic. All other persons were classified according to their reported race. For this statistical brief, the following classification by race and ethnicity was used: Hispanic (of any race), non-Hispanic Black, and non-Hispanic White. Due to small sample sizes, this analysis does not include non-Hispanic mothers who reported mixed race or who reported race as Asian, Native American, Alaskan Native, Native Hawaiian, or Pacific Islander.

Percentage of FPL

Percentage of the FPL was computed by dividing CPS family income by the applicable poverty line (based on family size and composition). The categories included in this statistical brief are (1) less than 138%, (2) between 139% and 250%, (3) between 251% and 400%, and (4) more than 400%.

About MEPS

The MEPS-HC collects nationally representative data on health care use, expenditures, sources of payment, and insurance coverage for the U.S. civilian noninstitutionalized population. The MEPS-HC is cosponsored by the Agency for Healthcare Research and Quality (AHRQ) and the National Center for Health Statistics (NCHS). More information about the MEPS-HC can be found on the MEPS Web site at https://www.meps.ahrq.gov/.

References

For a detailed description of the MEPS-HC survey design, sample design, and methods used to minimize sources of nonsampling error, see the following publications:

1. Vistnes, J., Lipton, B. and Miller, G.E. Uninsurance and Insurance Transitions Before and After 2014: Estimates for U.S., Non-Elderly Adults by Health Status, Presence of Chronic Conditions and State Medicaid Expansion Status. Statistical Brief #490. June 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://meps.ahrq.gov/mepsweb/data_files/publications/st490/stat490.shtml

2. Vistnes, J. and Miller G.E. Transitions in Health Insurance Coverage for Non-Elderly Adults in the U.S. Civilian Noninstitutionalized Population: 2013-2014 and Selected Preceding Two-Year Periods. Statistical Brief #489. June 2016. Agency for Healthcare Research and Quality, Rockville, MD. http://meps.ahrq.gov/mepsweb/data_files/publications/st489/stat489.pdf

3. Vistnes, J. and Cohen, S. Transitions in Health Insurance Coverage Over Time, 2012-2014 (Selected Intervals): Estimates for the U.S. Civilian Noninstitutionalized Adult Population under Age 65. Statistical Brief #467. February 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.meps.ahrq.gov/mepsweb/data_files/publications/st467/stat467.pdf

4. Vistnes J. and Cohen J. Gaining Coverage in 2014: New Estimates of Marketplace and Medicaid Transitions. Health Affairs. 2016; 35(10): 1825 - 9.

5. Cooper, P., Davis, K., and Miller, E. Trends in Enrollment, Offers, Eligibility and Take-up for Employer-Sponsored Insurance: Private Sector, by State Medicaid Expansion Status, 2008-2015. Statistical Brief #499. February 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.meps.ahrq.gov/mepsweb/data_files/publications/st499/stat499.pdf

6. Kaiser Family Foundation. Medicaid and CHIP Income Eligibility Limits for Pregnant Women as a Percent of the Federal Poverty Level as of January 1, 2022. https://www.kff.org/health-reform/state-indicator/medicaid-and-chip-income-eligibility-limits-for-pregnant-women-as-a-percent-of-the-federal-poverty-level/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

7. Kaiser Family Foundation. Medicaid Postpartum Extensions: Approved and Pending State Action as of October 6, 2022. https://www.kff.org/medicaid/issue-brief/medicaid-postpartum-coverage-extension-tracker/

8. Kaiser Family Foundation. Status of State Medicaid Expansion Decisions: Interactive Map. June 29, 2022. https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/

Suggested Citation

Monnet, J., and Hudson, J. E. M. Insurance Status of Mothers at the Time of Birth, by Demographic Characteristics, 2008-2019. Statistical Brief #547. February 2023. Agency for Healthcare Research and Quality, Rockville, MD https://meps.ahrq.gov/data_files/publications/st547/stat547.shtml

* * *
AHRQ welcomes questions and comments from readers of this publication who are interested in obtaining more information about access, cost, use, financing, and quality of healthcare in the United States. We also invite you to tell us how you are using this Statistical Brief and other MEPS data and tools and to share suggestions on how MEPS products might be enhanced to further meet your needs. Please email us at MEPSProjectDirector@ahrq.hhs.gov or send a letter to the address below:

Joel W. Cohen, PhD, Director
Center for Financing, Access and Cost Trends
Agency for Healthcare Research and Quality
5600 Fishers Lane, Mailstop 07W41A
Rockville, MD 20857

Figure displays: Trends in insurance coverage for birth mothers at time of birth, 2008-2019

Figure 1. Trends in insurance coverage for birth mothers at time of birth, 2008-2019

Year	2008	2009	2010	2011	2012	2013	2014	2015	2016	2017	2018	2019
Uninsured	8.6%	11.7%	11.5%	9.4%	13.5%	7.9%	10.5%	7.7%	7.9%	3.9%†	3.2%†	1.8%†
Public Only	35.8%	32.7%	35.4%	30.8%	34.1%	36.1%	34.6%	35.4%	32.6%	32.6%	31.8%	34.8%
Any Private	55.6%	55.6%	53.1%	59.8%	52.4%	56.0%	54.9%	56.9%	59.5%	63.5%	65.0%	63.3%
N	538	529	451	453	516	485	448	392	407	324	293	229

Source: Agency for Healthcare Research and Quality, Full-Year Consolidated files from the Medical Expenditure Panel Survey, Household Component, 2008-2019.
Notes: N represents the unweighted value for the denominator. † Indicates questionable precision (i.e., 0.30 ≤ Relative Standard Error (RSE) ≤ 0.50).

Figure displays: Distribution of insurance status of birth mothers at time of birth, Pre-ACA and Post-ACA

Figure 2. Distribution of insurance status of birth mothers at time of birth, Pre-ACA and Post-ACA

Insurance Status	Pre-ACA (2008-2013)	Post-ACA (2014-2019)
Any Private	55.4%	60.5%*
Public Only	34.2%	33.6%
Uninsured	10.4%	5.9%*
N	2,972	2,093

Source: Agency for Healthcare Research and Quality, Full-Year Consolidated files from the Medical Expenditure Panel Survey, Household Component, 2008-2019.
Notes: N represents the unweighted value for the denominator. * Denotes statistically significant difference between Pre-ACA and Post-ACA at 5% level or higher.

Figure displays: Distribution of insurance status of birth mothers at time of birth by age, Pre-ACA and Post-ACA

Figure 3. Distribution of insurance status of birth mothers at time of birth by age, Pre-ACA and Post-ACA

Age	13-19		20-29		30-39		40+
Insurance Status	Pre-ACA	Post-ACA	Pre-ACA	Post-ACA	Pre-ACA	Post-ACA	Pre-ACA	Post-ACA
Any Private	21.0%†	20.0%	45.1%	50.0%	72.4%	70.9%	64.8%	81.6%*
Public Only	70.3%	77.5%	42.8%	43.2%	19.3%	23.8%*	23.2%	13.1%
Uninsured	8.7%	2.5%*ˣ	12.1%	6.8%*	8.4%	5.3%*	12.0%†	5.4%†
N	244	97	1,591	1,004	1,049	909	88	83

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, Household Component, 2008-2019.
Notes: N represents the unweighted value for the denominator. * Denotes statistically significant difference between Pre-ACA and Post-ACA at 5% level or higher. ˣ Indicates RSE > 0.50, but upper bound of 95% confidence interval is less than 10%. † Indicates questionable precision (i.e., 0.30 ≤ RSE ≤ 0.50).

Figure displays: Distribution of insurance status of birth mothers at time of birth by race/ethnicity, Pre-ACA and Post-ACA

Figure 4. Distribution of insurance status of birth mothers at time of birth by race/ethnicity, Pre-ACA and Post-ACA

Race/Ethnicity	Hispanic		Non-Hispanic Black		Non-Hispanic White
Insurance Status	Pre-ACA	Post-ACA	Pre-ACA	Post-ACA	Pre-ACA	Post-ACA
Any Private	31.6%	41.7%*	30.5%	38.4%*	68.5%	73.1%
Public Only	46.3%	46.1%	61.5%	58.2%	24.7%	22.9%
Uninsured	22.1%	12.2%*	8.0%	3.4%*	6.8%	4.0%*
N	1,092	724	615	393	1,014	769

Figure displays: Distribution of Insurance Status of Birth Mothers at Time of Birth by Education, Pre-ACA and Post-ACA

Figure 5. Distribution of Insurance Status of Birth Mothers at Time of Birth by Education, Pre-ACA and Post-ACA

Education	Less than HS		HS/GED		Some College		BA Degree		More than BA Degree
Insurance Status	Pre-ACA	Post-ACA	Pre-ACA	Post-ACA	Pre-ACA	Post-ACA	Pre-ACA	Post-ACA	Pre-ACA	Post-ACA
Any Private	12.8%	13.7%	39.8%	38.5%	62.6%	61.5%	83.1%	84.8%	94.6%	92.3%
Public Only	66.9%	67.9%	48.8%	55.1%	29.4%	33.3%	8.0%	12.8%	4.2%†	4.6%
Uninsured	20.4%	18.4%	11.4%	6.4%*	8.0%	5.2%	8.9%	2.4%*†	1.3%ˣ	3.0%ˣ
N	749	360	1,093	756	440	364	409	362	227	224

Figure displays: Distribution of insurance status of birth mothers at time of birth by percentage of the federal poverty level, Pre-ACA and Post-ACA

Figure 6. Distribution of insurance status of birth mothers at time of birth by percentage of the federal poverty level, Pre-ACA and Post-ACA

% of FPL	0-138% of FPL		139-250% of FPL		251-400% of FPL		> 400% of FPL
Insurance Status	Pre-ACA	Post-ACA	Pre-ACA	Post-ACA	Pre-ACA	Post-ACA	Pre-ACA	Post-ACA
Any Private	17.2%	21.9%	56.6%	55.6%	79.4%	85.9%	93.4%	95.7%
Public Only	67.1%	69.8%	32.8%	34.6%	12.2%	11.7%	2.8%†	1.9%†
Uninsured	15.7%	8.3%*	10.6%	9.8%	8.5%	2.4%*†	3.8%	2.3%†
N	1,569	1,041	579	396	389	280	434	376

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, Household Component, 2008-2019.
Notes: N represents the unweighted value for the denominator. * Denotes statistically significant difference between Pre-ACA and Post-ACA at 5% level or higher. † Indicates questionable precision (i.e., 0.30 ≤ RSE ≤ 0.50).

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STATISTICAL BRIEF #547: Insurance Status of Mothers at the Time of Birth, by Demographic Characteristics, 2008-19