In Reply In response to our JAMA Insights article on noninvasive prenatal genetic screening, Drs Cohen and Westover advocate for universal public and private reimbursement for cfDNA tests, arguing that it will reduce disparities in access to prenatal screening. Approximately 40% of US pregnancies are supported by Medicaid. This population is, by definition, confined to the lowest end of the income scale and to women who cannot access other forms of health care coverage. These women are predominantly younger and less likely to present for care during the first trimester, which is why many Medicaid programs may not consider a more expensive aneuploidy screen to be a priority. The most prominent conditions adversely affecting pregnancies in this population are preeclampsia, risk of preterm birth, and preventable maternal-fetal morbidities due to complications, possibly linked to the rate of untreated chronic disease such as obesity and diabetes. None of these are detectable by commercial cfDNA panels but are significantly more likely to be detected and treated when women have consistent prenatal care. In declining immediate expanded reimbursement for cfDNA, many Medicaid programs are simply making rational decisions about scarce resources and the real needs of their patients.
