Marketplace coverage during pregnancy: what can we learn from state-level variation?

Introduction: Little is known about the role of the Affordable Care Act Marketplaces in providing health insurance coverage for pregnant women. Methods: Using PRAMS survey data from 2018-2019 from 36 states and Washington, DC, we estimated the percentage of women with a pregnancy resulting in live birth who had Marketplace coverage during pregnancy, overall, by state, by federal poverty level (FPL) categories, and by state-based vs federal Marketplace status. We also describe the preconception and postpartum insurance status and sociodemographic and health characteristics of pregnant Marketplace enrollees. Results: Overall, 4.9% of women who had a live birth had Marketplace coverage during pregnancy in 2018-2019. This percentage varied by state (1.6% in Iowa to 13.1% in Maryland) and was significantly higher in state-based Marketplaces vs federally-run/facilitated Marketplaces (8.0% vs 3.5%) and among premium subsidy-eligible women (ie, <400% FPL). Pregnant Marketplace enrollees were more similar to pregnant women with Medicaid than those with private insurance in terms of sociodemographic characteristics and clinical predictors of adverse pregnancy outcomes. Conclusion: Marketplace coverage is a small, but important coverage source for women who had a live birth, insuring 1 in 20 women in our sample. The extent to which pandemic-era and recent policies affected Marketplace coverage of this population merits further investigation.