Association of the Affordable Care Act Dependent Coverage Provision With Prenatal Care Use and Birth Outcomes

IMPORTANCE The effect of the Affordable Care Act (ACA) dependent coverage provision on pregnancy-related health care and health outcomes is unknown. OBJECTIVE To determine whether the dependent coverage provision was associated with changes in payment for birth, prenatal care, and birth outcomes. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study, using a differences-indifferences analysis of individual-level birth certificate data comparing live births among US women aged 24 to 25 years (exposure group) and women aged 27 to 28 years (control group) before (2009) and after (2011-2013) enactment of the dependent coverage provision. Results were stratified by marital status. MAIN EXPOSURES The dependent coverage provision of the ACA, which allowed young adults to stay on their parent's health insurance until age 26 years. MAIN OUTCOMES AND MEASURES Primary outcomes were payment source for birth, early prenatal care (first visit in first trimester), and adequate prenatal care (a first trimester visit and 80% of expected visits). Secondary outcomes were cesarean delivery, premature birth, low birth weight, and infant neonatal intensive care unit (NICU) admission. RESULTS The study population included 1 379 005 births among women aged 24 to 25 years (exposure: 299024 in 2009; 1079 981 in 2011-2013), and 1 551 192 births among women aged 27 to 28 years (control: 325 564 in 2009; 1 225 628 in 2011-2013). From 2011-2013, compared with 2009, private insurance payment for births increased in the exposure group vs the control group; Medicaid payment and self-payment decreased. Early and adequate prenatal care increased and preterm birth decreased. There were no significant changes in low birth weight, NICU admission, or cesarean delivery. In stratified analyses, changes in payment for birth, prenatal care, and preterm birth were concentrated among unmarried women [GRAPHICS] CONCLUSIONS AND RELEVANCE In this study of nearly 3 million births among women aged 24 to 25 years vs those aged 27 to 28 years, the Affordable Care Act dependent coverage provision was associated with increased private insurance payment for birth, increased use of prenatal care, and modest reduction in preterm births, but was not associated with changes in cesarean delivery rates, low birth weight, or NICU admission.