Examining the Impact of the COVID-19 Public Health Emergency on Maternal Mental Health in ACA Expansion and Non-Expansion States

One in five pregnant women experience poor mental health, negatively impacting both the mother and child during pregnancy and after childbirth. In March 2020, in response to the Covid-19 pandemic, Congress declared a Public Health Emergency (PHE) and imposed a continuous coverage requirement, which stopped state Medicaid programs from unenrolling people from the Medicaid program for any reason. In my study, I measured the effects of the PHE on the mental health outcomes, and trends in insurance enrollment, of pregnant women in ACA-expansion states and non-expansion states.

Under the Medicaid Expansion provision of the Affordable Care Act, individuals who did not qualify for Medicaid coverage under the traditional model are eligible for coverage if their incomes are up to 138% of the federal poverty line (FPL). Due to the continuous coverage rule of the Covid-19 Public Health Emergency, individuals who were pregnant at the time of the emergency’s declaration have obtained Medicaid coverage for a longer period than the traditional period for pregnant individuals, in both Medicaid expansion and non-expansion states. I used data from the Centers for Disease and Control Prevention’s (CDC) Behavioral Risk Factor Surveillance Survey (BRFSS) questionnaires for years 2018-2021 to analyze respondents’ answers to a question describing their mental health during pregnancy as a measure of mental health, and a question indicating their primary health coverage to measure their insurance enrollment. 

I hypothesized that the PHE would have a positive effect on mental health among pregnant women, have a larger effect on mental health among pregnant women in non-expansion states, and increase the percentage of pregnant women with health insurance. To test these predictions, I first created a series of descriptive line graphs (featured below) to illustrate the trends in mental health and insurance coverage among pregnant women in ACA expansion and non-expansion states.

Ultimately, these graphs illustrate that mental health was better among pregnant women in expansion states after the PHE. Further, health insurance coverage trends varied depending on the type of coverage and state expansion status. 

Next, I performed difference- in-difference regressions, controlling for race, education, and income in some models, and ultimately settled on a model that controlled for all covariates when analyzing the data. I found that:

1. The PHE had some improvement on the mental health of pregnant women 
2. The PHE had a larger effect among pregnant women in ACA expansion states than pregnant women in non-expansion states.
3. The PHE affected the nature of insurance coverage, but the exact mechanism that ties the PHE to insurance coverage is not clear.

Due to the presence of Covid-19 and its lasting impact, it’s difficult to differentiate between the effects of the PHE and Covid. Therefore, while the results were based on statistically significant values revealed by the regressions, it is not certain that other factors not controlled for in the study, such as Covid, did not play a role.

The Covid-19 pandemic was a unique public health and international emergency which presented an array of unprecedented issues and affected subgroups of the population differently, including pregnant women. The PHE was a unique policy intervention aimed at addressing many of these issues, including the overall health of the nation. This research aimed to fill the gap of knowledge surrounding the impact of the PHE on the mental health of pregnant women.

Tateana Cutter will graduate this May with a B.S. in Healthcare Management and Policy and minor in Law and Public Policy from the O’Neill School of Public and Environmental Affairs. While at IU, Tateana was involved in several student organizations, such as the Black Student Union and Tau Chapter of Alpha Kapp Alpha Sorority, Inc. In addition, Tateana is the recipient of the 2023 P.J. and Hilda Hill Award. In the fall, Tateana will be attending Emory University School of Law to pursue her JD. You can connect with Tateana via Linkedin: www.linkedin.com/in/tateana-cutter