NURS 491 Week 7 Impact of Healthcare Reform: Team Presentation Example

The Affordable Care Act and Maternal-Newborn Nursing: Coverage, Care and the Postpartum Year

Slide 1: Our Specialty and Our Question

• Maternal-newborn nursing
• How has the Affordable Care Act changed care for mothers and infants?
• Four parts: the law, outcomes, the postpartum year, the gaps

Speaker notes: Our team includes two labor and delivery nurses, a postpartum nurse and a public health nurse, so we chose maternal-newborn nursing. Each of us took one part of the question and brought two recent studies. We will finish with what the changes mean for nurses.

Slide 2: Why Maternal Health Needed Reform

• Births are expensive, and many families were uninsured or underinsured
• Coverage often ended weeks after delivery
• Most serious complications can occur after discharge

Speaker notes: Before the ACA, a woman could be covered during pregnancy and lose coverage soon after, just as complications like postpartum hypertension, cardiomyopathy and depression appear. Reform aimed to make coverage more complete and longer lasting.

Slide 3: Maternity Care as an Essential Benefit

• Maternity and newborn care required in individual and small-group plans
• Pregnancy can no longer be treated as a preexisting condition
• Young adults can stay on a parent's plan until age 26

Speaker notes: Before 2014, many individual market plans excluded maternity care or charged extra for it. The ACA made maternity and newborn care one of ten essential health benefits and stopped insurers from refusing or pricing coverage on the basis of a prior condition, pregnancy among them.

Slide 4: Preventive Services Without Cost Sharing

• Well-woman visits and gestational diabetes screening
• Breastfeeding support, counseling and equipment
• Contraception counseling and methods

Speaker notes: Many plans must cover recommended preventive services for women without copays, including lactation support and breast pumps. For postpartum nurses, this means we can refer mothers for lactation help and tell them their plan should cover a pump.

Slide 5: Medicaid Expansion

• Adults with incomes to 138% of poverty became eligible
• Optional for states after a 2012 Supreme Court ruling
• Virginia expanded in 2019

Speaker notes: Medicaid already covered many pregnant women, but expansion covered low-income women before and after pregnancy, which matters for chronic conditions such as hypertension and diabetes that affect pregnancy outcomes. Expansion became optional for states after the Supreme Court's 2012 decision, so its effects vary by state.

Slide 6: Part 2, Did Outcomes Change?

• Coverage is a means, not an end
• We looked for effects on care and complications
• Evidence is mostly observational

Speaker notes: The second part of our presentation asks whether the law changed outcomes, not just coverage. Most of the evidence comes from comparing expansion and nonexpansion states over time, which is strong but not randomized.

Slide 7: Eclampsia in Expansion States

• 21.5 million birth certificates, 2010 to 2018
• Eclampsia fell 1.6% in expansion versus nonexpansion states
• Consistent across race, education and poverty groups

Speaker notes: Guglielminotti et al. (2023) compared 16 states that expanded Medicaid in 2014 with 13 that did not. In expansion states, eclampsia incidence had been rising and then fell after expansion, while nonexpansion states showed the reverse, an overall 1.6% relative decrease. The authors call it small and note its clinical significance remains to be determined.

Slide 8: Longer Postpartum Coverage in Oregon

• 73,669 postpartum individuals
• Coverage lasted about three months longer after expansion
• More outpatient visits across the first year

Speaker notes: Pradhan et al. (2023) linked Oregon birth certificates and Medicaid claims and found that after expansion, postpartum coverage lasted about 3.1 months longer for women previously eligible and 2.8 months longer for newly eligible women, with more outpatient visits through the first year after birth.

Slide 9: Coverage and Postpartum Visits

• Systematic review of 28 U.S. studies
• More comprehensive coverage: likely more postpartum visits
• Possible fewer preventable readmissions and ED visits

Speaker notes: Saldanha et al. (2023) reviewed 28 studies covering more than 3.4 million people. Moderate-strength evidence suggested that more comprehensive insurance was associated with greater attendance at postpartum visits, and low-strength evidence suggested fewer preventable readmissions and emergency visits.

Slide 10: Medicaid Versus Commercial After Birth

• Colorado: 44,471 people with Medicaid-paid births
• Commercial coverage: more primary care, fewer ED visits
• Medicaid: about $796 less out of pocket

Speaker notes: Gordon et al. (2022) compared people who stayed on Medicaid after birth with those who moved to commercial insurance. Commercially insured mothers used more primary care and less emergency care but paid about $796 more out of pocket. Coverage type shapes both access and cost.

Slide 11: Part 3, The Postpartum Year

• Most maternal deaths can occur after birth
• Pregnancy Medicaid used to end at about 60 days
• The American Rescue Plan of 2021 allowed 12 months

Speaker notes: The third part of our presentation focuses on the year after birth. Under traditional rules, pregnancy Medicaid ended at the end of the month containing the sixtieth day postpartum. Building on the ACA's expansion, the American Rescue Plan of 2021 allowed states to extend coverage to a full year.

Slide 12: What the 12-Month Extension Did

• North Carolina: 353,957 Medicaid-funded births
• Covered at 12 months: 26.5% before, 97.1% after
• Primary care use: 25.3% to 71.4%

Speaker notes: Swartz et al. (2025) found that after North Carolina adopted the extension, nearly all Medicaid-covered mothers remained continuously covered at 12 months, and use of primary care, contraception, mental health and substance use care rose substantially, although some early postpartum visits were delayed.

Slide 13: Mental Health After Birth

• Mental health visits rose from 7.5% to 25.7% with extension
• Coverage for immigrants raised diagnosis of perinatal conditions
• Diagnosis does not guarantee treatment

Speaker notes: Rodriguez et al. (2024) studied Oregon's extension of Emergency Medicaid to cover prenatal and postpartum care for low-income immigrants. Prenatal coverage increased diagnosis of perinatal mental health conditions by 4.1 percentage points, and postpartum coverage added 2.6 points, but postpartum treatment did not significantly increase.

Slide 14: What This Means on the Postpartum Unit

• Screen every mother for depression before discharge
• Confirm her coverage extends through the year
• Make the first follow-up appointment before she leaves

Speaker notes: Nurses can turn coverage into care. Our postpartum unit now screens every mother, checks her coverage with the case manager and schedules the first visit before discharge, especially for mothers with hypertension.

Slide 15: Part 4, Gaps That Remain

• Not every state expanded Medicaid
• Racial disparities persist
• Births still cause medical debt

Speaker notes: The last part of our presentation looks at what reform has not fixed. Coverage still depends on where a mother lives, disparities have not closed and many families still struggle with bills after a birth.

Slide 16: Coverage Gaps by Race

• Prepandemic uninsurance among Black postpartum women: 16.5% in nonexpansion states
• 6.4% in expansion states
• The Black-White gap remained after continuous coverage

Speaker notes: Janevic et al. (2026) found that continuous Medicaid coverage during the pandemic reduced postpartum uninsurance among Black women in nonexpansion states, but the Black-White disparity in uninsurance remained unchanged, because White women's gains came largely through private insurance.

Slide 17: Medical Debt After Childbirth

• 19.8% of postpartum women had trouble paying medical bills
• 48% higher odds than women who had not given birth
• True even for privately insured women

Speaker notes: Cahn et al. (2023) analyzed national survey data and found that women who had given birth in the past year had 48% higher adjusted odds of problems paying medical bills. Insurance reduced but did not remove the financial burden of birth.

Slide 18: Implications for Nurses

• Know the coverage rules in your state
• Partner with case managers and social workers
• Advocate for policies that close remaining gaps

Speaker notes: Maternal-newborn nurses are often the first to hear a mother say she cannot afford a medication or a visit. Knowing what her plan covers, who can help her enroll and which policies affect her care lets us act rather than sympathize.

Slide 19: A Christian View of Reform

• Care for the vulnerable is a biblical theme
• Mothers and infants are among the most vulnerable
• Nurses serve as advocates

Speaker notes: Scripture repeatedly calls God's people to defend the weak and the fatherless (English Standard Version Bible, 2001/2016, Psalm 82:3). Whatever our political views of the law, caring for mothers and infants who lack coverage is part of our calling as Christian nurses.

Slide 20: Conclusion

• The ACA expanded coverage and some outcomes improved
• The postpartum year is where coverage matters most
• Nurses connect policy to the bedside

Speaker notes: The ACA did not solve maternal health, but it opened doors that nurses can help mothers walk through. A coverage card in a mother's wallet becomes care only when a nurse makes sure she uses it. Thank you; we welcome your questions.

References

Cahn, J., Sundaram, A., Balachandar, R., Berg, A., Birnbaum, A., Hastings, S., Makansi, M., Romano, E., Majidi, A., McCormick, D., & Gaffney, A. (2023). The association of childbirth with medical debt in the USA, 2019-2020. Journal of General Internal Medicine, 38(10), 2340-2346. https://doi.org/10.1007/s11606-023-08214-3

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

Gordon, S. H., Hoagland, A., Admon, L. K., & Daw, J. R. (2022). Comparison of postpartum health care use and spending among individuals with Medicaid-paid births enrolled in continuous Medicaid vs commercial insurance. JAMA Network Open, 5(3), e223058. https://doi.org/10.1001/jamanetworkopen.2022.3058

Guglielminotti, J., Daw, J. R., Friedman, A. M., Landau, R., & Li, G. (2023). Medicaid expansion and risk of eclampsia. American Journal of Obstetrics & Gynecology MFM, 5(8), 101054. https://doi.org/10.1016/j.ajogmf.2023.101054

Janevic, T., Kim, H., Ng, A., Howell, F. M., Liu, S. H., Fox, A., & Weber, E. (2026). Racial inequities in postpartum coverage during Medicaid continuous coverage: Evidence from Affordable Care Act expansion versus nonexpansion states. American Journal of Preventive Medicine, 71(1), 108320. https://doi.org/10.1016/j.amepre.2026.108320

Pradhan, S., Harvey, S. M., Bui, L. N., & Yoon, J. (2023). Postpartum Medicaid coverage and outpatient care utilization among low-income birthing individuals in Oregon: Impact of Medicaid expansion. Frontiers in Public Health, 11, 1025399. https://doi.org/10.3389/fpubh.2023.1025399

Rodriguez, M. I., Martinez-Acevedo, A., Kaufman, M., Nacev, E. C., Mackiewicz-Seghete, K., & McConnell, K. J. (2024). Diagnosis of perinatal mental health conditions following Medicaid expansion to include low-income immigrants. JAMA Network Open, 7(2), e240062. https://doi.org/10.1001/jamanetworkopen.2024.0062

Saldanha, I. J., Adam, G. P., Kanaan, G., Zahradnik, M. L., Steele, D. W., Chen, K. K., Peahl, A. F., Danilack-Fekete, V. A., Stuebe, A. M., & Balk, E. M. (2023). Health insurance coverage and postpartum outcomes in the US: A systematic review. JAMA Network Open, 6(6), e2316536. https://doi.org/10.1001/jamanetworkopen.2023.16536

Swartz, J. J., Lawson Avis, A., Bundorf, M. K., & Domino, M. E. (2025). Postpartum Medicaid use in birthing parents and access to financed care. JAMA Health Forum, 6(6), e251630. https://doi.org/10.1001/jamahealthforum.2025.1630