The Affordable Care Act (ACA) dependent coverage provision correlates with increased private insurance payment for birth, increased use of prenatal care, and a modest reduction in preterm births, but not cesarean delivery rates, low birth weight, or neonatal intensive care unit admission, according to the results of a study published in JAMA.

Jamie R. Daw, MSc, of the Department of Health Care Policy at Harvard Medical School, and Benjamin D. Sommers, MD, PhD, of the Department of Health Policy and Management, Health Policy and Economics at the Harvard T.H. Chan School of Public Health in Boston, Massachusetts, conducted a retrospective cohort study using differences-in-differences analysis of individual-level birth certificate data.

The researchers compared live births in US women age 24 to 25 years (exposure group) and women age 27 to 28 years (control group) before and after the enactment of the dependent coverage provision. Primary outcomes were payment source for birth, early prenatal care, and adequate prenatal care. Secondary outcomes included cesarean delivery, premature birth, low birth weight, and infant neonatal intensive care unit admission.

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The study population included 1,379,005 births among the exposure group (299,024 in 2009; 1,079,981 in 2011-2013) and 1,551,192 births in the control group (325,564 in 2009; 1,225,628 in 2001-2013). Private insurance payment for births increased in the exposure group vs the control group between 2009 and 2011 to 2013, whereas Medicaid payment and self-payment decreased. 

In the exposure group, early prenatal care increased from 70% to 71.6% and adequate prenatal care increased from 73.5% to 74.8% after the initiation of the ACA. In the control group, early prenatal care increased from 75.7% to 76.8% and adequate prenatal care increased from 77.5% to 78.8% after initiation of the ACA. Preterm birth decreased from 9.4% to 9.1% after implementation of the ACA for the exposure group and from 9.1% to 8.9% for the control group.

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The authors note that the improvement in prenatal care seen in this study is consistent with research from previous studies that have shown that women with preconception coverage receive better access to health care in early pregnancy and that having private insurance at delivery is associated with higher rates of continuous coverage before, during, and after pregnancy than pregnancy-related Medicaid coverage.


Daw JR, Sommers BD. Association of the Affordable Care Act dependent coverage provision with prenatal care use and birth outcomes. JAMA. 2018;319:579-587.