Margerison et al. Respond to "Medicaid Policy and Reproductive Autonomy".
Margerison et al. Respond to "Medicaid Policy and Reproductive Autonomy".
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马杰里森等人。
DOI：
10.1093/aje/kwaa291
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发表时间：
2021
影响因子：
5
通讯作者：
MacCallum-Bridges,Colleen
中科院分区：
文献类型：
--
作者：
Margerison,ClaireE;Kaestner,Robert;Chen,Jiajia;MacCallum-Bridges,Colleen
根据《平价医疗法案》扩大医疗补助覆盖范围，使报告拥有医疗保险的育龄妇女的比例总体上增加了至少9个百分点，其中没有受抚养子女的妇女增加幅度更大（1，2）。然而，在我们的研究中（3），我们发现在怀孕前一年扩大医疗补助资格与孕前或怀孕健康的改善无关，也没有降低不良出生结局的发生率。这些“无效”的发现与之前的报告一致，即在怀孕期间将医疗补助扩大到妇女也没有降低不良出生结局的患病率（4，5）。我们感谢Jarlenski博士（6）对我们文章的周到评论。我们同意她关于生殖自主的伦理基础和潜在健康益处的观点。因此，我们同意医疗补助应包括确保这种自主权的政策和福利。我们也同意，医疗补助覆盖范围可以做更多的工作，以促进健康的生命过程中，不仅为妇女和婴儿，但为所有个人和家庭。几十年来，公共卫生和政策试图通过只关注怀孕9个月来改善妊娠健康和结果，但在美国，对降低早产、低出生体重或孕产妇死亡率的高比率或差异收效甚微。医疗补助范围内的一个范式转变，即关注所有个人在生命过程中的生殖自主权，无论性别或怀孕状况如何，确实会带来变革。然而，我们目前的研究结果并不一定表明医疗补助对促进生育自主权毫无作用。事实上，我们以前发表的研究结果（7）（和其他人的研究结果（8-11））表明，《平价医疗法案》的避孕规定与处方避孕药的使用增加有关，特别是长效可逆避孕药（8-11），但与总体意外怀孕无关（7）。然而，在有政府赞助的保险的女性中，与2008-2010年相比，2013-2015年的意外怀孕确实有所减少（7），这表明政府赞助的医疗保险可能发挥重要作用（如医疗补助）在促进生育自主性方面的作用。我们还注意到，我们发现扩大医疗补助资格和健康结果之间没有关联，这可能不会延伸到产后时期，正如Jarlenski指出的那样（6）。目前，在怀孕期间获得医疗补助的妇女在产后60天失去资格，除非她们能够根据收入和/或父母资格准则重新获得资格。然而，11.7%的妊娠相关死亡发生在产后43-365天（12），高达80%的药物相关妊娠相关死亡发生在产后下半年（13，14）。将医疗补助覆盖范围扩大到怀孕后的低收入妇女，可以促进更持续的护理，并提供更多机会来识别和支持患有身体并发症，心理健康症状或药物使用的妇女。然而，仅仅扩大医疗补助覆盖范围，而不改变妇女在6周内只参加1次产后访视的建议可能是不够的。事实上，美国妇产科学院建议产后护理是一个持续的过程，而不是一次访问（15）。我们同意Jarlenski博士对现有数据的局限性（例如，测量误差）的担忧，以确定健康保险对孕前和妊娠健康和婴儿健康的全部后果。我们也同意，健康只是部分地取决于与...
Expansion of Medicaid coverage under the Affordable Care Act has increased the percentage of reproductive-age women who report having health insurance by at least 9 percentage points overall, with higher increases among women without dependent children (1, 2). Yet, in our study (3), we found that expanded Medicaid eligibility during the year prior to conception was not associated with improvements in prepregnancy or pregnancy health and did not reduce the prevalence of adverse birth outcomes. These “null” findings are consistent with prior reports that expansion of Medicaid to women during pregnancy also did not reduce the prevalence of adverse birth outcomes (4, 5). We thank Dr. Jarlenski (6) for her thoughtful comments on our article. We agree with her points regarding the ethical foundation and potential health benefits of reproductive autonomy. Accordingly, we agree that Medicaid should include policies and benefits that ensure such autonomy. We also agree that Medicaid coverage could do more to promote health over the life course, not only for women and infants but for all individuals and families. Decades of public health and policy attempts to improve pregnancy health and outcomes by focusing only on the 9 months of pregnancy have done little to reduce high rates of or disparities in preterm delivery, low birth weight, or maternal mortality in the United States. A paradigm shift within Medicaid to focus on reproductive autonomy over the life course for all individuals, regardless of sex or pregnancy status, would indeed be transformative. However, our current findings do not necessarily suggest that Medicaid does nothing to promote reproductive autonomy. In fact, our previously published findings (7)(and those of others (8–11)) showed that the Affordable Care Act’s contraception mandate was associated with increased uptake of prescription contraceptives, particularly long-acting reversible contraceptives (8–11), but was not associated with unintended pregnancy overall (7). However, among women with government-sponsored insurance, unintended pregnancy did decrease in 2013–2015 as compared with 2008–2010 (7), indicating a potentially important role for governmentsponsored health insurance (such as Medicaid) in promoting reproductive autonomy.We also note that our finding of no association between expanded Medicaid eligibility and health outcomes may not extend to the postpartum period, as Jarlenski pointed out (6). Currently, women with Medicaid coverage during pregnancy lose eligibility 60 days postpartum unless they can requalify under income and/or parental eligibility guidelines. Yet, 11.7% of pregnancy-related deaths occur 43–365 days postpartum (12), and up to 80% of drug-related pregnancy-associated deaths occur in the second half of the postpartum year (13, 14). Extending Medicaid coverage to low-income women after pregnancy could facilitate more continuous care and offer more opportunities to identify and support women struggling with physical complications, mental health symptoms, or substance use. However, simply extending Medicaid coverage with no change in the recommendation that women attend only 1 postpartum visit at 6 weeks may be insufficient. Indeed, the American College of Obstetricians and Gynecologists recommends that postpartum care be an ongoing process rather than a single visit (15). We share Dr. Jarlenski’s concerns about the limitations (eg, measurement error) of available data to identify the full consequences of health insurance for preconception and pregnancy health and infant health. We also agree that health is determined only partly by interaction with the …