Health Insurance and Infant Mortality in the U.S.

Privately insured infants had better health outcomes and a lower risk of death in their first year of life than infants insured by Medicaid.

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A newborn baby. The joy. The anticipation. The anxiety. A plethora of emotions surround welcoming a new member of the family home. Few parents anticipate that their baby may not meet the milestone of their first birthday. Yet the devastating loss of a newborn is all too real for many families. In 2022, 5.60 infants per 1,000 live births died before their first birthday. This number is higher than it has been in 20 years.

Infant mortality in the United States is influenced by many nuanced and complex factors. The causes of death in the neonatal period (days 0-27 after birth) tend to differ from the post-neonatal period (days 28-365 after birth). Deaths in the neonatal period are more commonly associated with disorders related to premature birth and low birth weight. In the post-neonatal period, deaths are usually caused by accidents, infections, and sudden infant death syndrome.

Few studies have examined the effect of health insurance type on our national infant mortality rates. We recently compared outcomes of pregnant mothers with private insurance to those with Medicaid insurance. Our objective was to determine if insurance type was associated with differences in infant mortality and other poor infant outcomes, such as low birth weight, preterm birth, and late prenatal care. Our study controlled for factors, such as education level, tobacco exposure, and maternal risk factors which could impact the results.

We analyzed data from a nationally representative cohort of 13,562,625 infants. Fifty-four percent of these infants’ mothers were privately insured and forty-six percent were insured by Medicaid. We found privately insured infants had a lower rate of infant death compared to those insured by Medicaid (2.75 vs. 5.30 deaths per 1,000 live births). Infants with private insurance also had a lower risk of death in the post-neonatal period (0.81 vs. 2.41 deaths per 1,000 births) compared to mothers with Medicaid.

[I]nfant health and well-being will only improve (and, by extension, infant mortality will only decrease) with better access to quality health care for all women and their babies.

Higher rates of death in the post-neonatal period for those with Medicaid was also noted in another study performed by the National Institute of Child Health and Human Development Neonatal Research Network. Extremely preterm babies without private insurance had an increased likelihood of dying after being discharged from the Neonatal Intensive Care Unit.

The Affordable Care Act, passed in March 2010, allowed states to initiate presumptive eligibility, which would provide pregnant women with access to presumptive coverage prior to completing the application process. However, as of 2023, only 30 states have accepted this provision. As a result, many women may undergo weeks, even the entirety of the first trimester, attempting to access prenatal care.

This delay in access to prenatal care is extremely concerning as the first trimester is a critical time during the pregnancy. In this stage, the fetus undergoes organogenesis, the development of critical organs such as the heart, lungs, kidneys, and brain. Significant weight and length growth also occur. This may account for our findings that women with private insurance had a greater rate of first trimester prenatal care, which suggests better access to early pregnancy care and screening.

Our study did not include data from uninsured mothers, which is an important limitation of our analysis. It is vital to consider how having no insurance may affect infant death rate and poor health outcomes, as studies have suggested babies born to self-pay mothers have worse outcomes than private and Medicaid groups. Since a large portion of mothers who pay out-of-pocket are undocumented immigrants, they may have even greater difficulties accessing health care.

The results of our study, although disconcerting, are not surprising. Medicaid insurance provides a key resource and service to mothers who otherwise would likely have even worse pregnancy outcomes and infant death rates. However, infant health and well-being will only improve (and, by extension, infant mortality will only decrease) with better access to quality health care for all women and their babies. Every parent deserves to have the joy of that first birthday, and many more after that.