What will the united states election mean for Black-white disparities in maternal and child health?

In October 2017, the LA Times reported the story of Cassaundra Lynn Perkins, a 21-year-old Texas mother who had recently given birth to premature twins. She had been ill throughout her pregnancy, culminating in liver failure and the birth of her twins at just six months. Perkins was readmitted to a healthcare facility after having a baby and died 3 days later, abandoning three children to be raised by her mother.

Cassaundra’s life and death are emblematic of wide racial gaps in maternal health in America. Non-Hispanic (NH) Black women that are pregnant are disproportionately much more likely than non-Black women that are pregnant to be disabled, have chronic illnesses, or both.

In comparison to NH white females, also, they are more than twice as more likely to experience life threatening pregnancy complications and approximately 2.5 times much more likely to die from pregnancy-related causes.

Like Cassaundra’s twins, Black infants are more likely to be born preterm and with low birth weight in accordance with white infants. Black infants also experience the highest infant mortality rates of any racial or ethnic group.

The consequences of these health inequities - poorer health and well-being among surviving mothers and long-term adverse impacts on health insurance and labor market outcomes of their children - have important implications for both population health insurance and the U.S. economy most importantly.

The upcoming U.S. elections are some of the most consequential in recent memory, and healthcare policies that will impact the fitness of Black females and infants are on the ballot.

Focusing on how policy agendas advanced by the Trump-Pence and Biden-Harris administrations might widen or narrow Black-white gaps in maternal and child health is imperative.

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These include policies relating to the individual Protection and Affordable Care Act (ACA), hospital-level reforms, racial bias in healthcare, and family planning.

While I focus exclusively on healthcare policies here, ensuring equal usage of quality care is merely a starting point for addressing these longstanding health inequities.

Affordable Care Act

The ACA was landmark legislation made to expand insurance plan in the U.S. among low-income populations dramatically.

Several key parts of the ACA, including Medicaid expansions - 38 states and the District of Columbia as of October 2020, insurance subsidies and dependent coverage provisions have dramatically decreased rates of uninsurance and financial barriers to care among low-income women of reproductive age.

That is particularly true of women without children, women of color, or both, including Black women. The ACA also mandates that insurance firms cover essential reproductive health services such as for example maternity care.

Since the beginning, the Trump administration spent some time working to scale back Medicaid and overturn the ACA, mainly through executive orders. The Supreme Court is set to hear oral arguments in California v. Texas on November 10, a case that challenges the constitutionality of regulations.

If the ACA is declared unconstitutional, many Americans will eventually lose their health insurance. Regardless of the promises that the Trump administration’s yet-to-be-revealed new healthcare plan covers all pre-existing conditions and lower healthcare insurance premiums, there is little information about how they'll implement this new plan.

While it isn't fully clear what this would mean for birth outcomes, evidence from Tennessee shows that sudden Medicaid disenrollment increases financial distress, cost barriers to care, and avoidable hospital visits.

On the other hand, the Biden-Harris campaign promises to safeguard and fortify the ACA. The campaign platform pledges to provide Americans with a public medical health insurance option - such as a type of Medicare, expand coverage and lower insurance costs via tax credits, and extend premium-free public option coverage to eligible low-income Americans in states that have chosen not to expand Medicaid.

The question is: would strengthening the ACA improve racial disparities in maternal and child health?

On the main one hand, the ACA has improved rates of preconception counseling, preconception folic acid use, and preconception or postpartum insurance plan.

However, there is little evidence that dependent coverage provisions and Medicaid expansions improve birth outcomes such as for example low birth weight, preterm births, or neonatal intensive care unit admissions. These findings are steady with those from prior studies examining the original impacts of the prenatal Medicaid expansions of the 1980s and early 90s on birth outcomes.

Yet, studies examining these outcomes separately by race or ethnicity find that the positive benefits of the ACA Medicaid are almost exclusively concentrated among black mothers, including declines in preterm birth, infant mortality, and maternal mortality. For an exception, see here.

Another important issue is that the in utero ramifications of public medical health insurance expansions might not emerge until decades after implementation. Given this, it really is plausible that further expanding Medicaid could reduce Black-white disparities in maternal and child health, particularly in Southern states that contain chosen never to expand the program.

Finally, if the Biden-Harris administration prevails, it is very important to monitor the financing and delivery of healthcare in order to avoid exacerbating maternal and child health disparities.

Both ACA insurance exchanges and most Medicaid expansions depend on capitated private insurance policies, such as for example managed care, underscoring the general shift from providing insurance through charge for service options in the U.S. As the intention of managed care is to regulate healthcare costs, it can have unintended consequences, such as for example worsened prenatal care use and birth outcomes.

Findings from Texas show that the implementation of managed care boosts preterm birth and infant mortality among Hispanic infants but worsens these outcomes among Black infants.

There is suggestive, though not definitive, evidence in the Texas case that insurance firms may have targeted women with less complicated and costly births, such as for example Hispanic mothers, to regulate costs. Due to this, states must consider whether managed care organizations have incentives to activate in risk selection when negotiating contracts.