The United States is the only industrialized nation with a maternal mortality rate that is on the rise, increasing 26 percent between 2000 and 2014. Also concerning are the stark racial disparities in maternal mortality: Black women are three to four times more likely to die from a pregnancy-related complication than non-Hispanic white women, and American Indian/Alaska Native women are two and a half times more likely to die from a pregnancy-related complication than non-Hispanic white women. Notably, these disparities apply across education levels and persist even after controlling for differences in household income.
An increasing number of maternal deaths—which are defined as deaths during pregnancy and up to 365 days after—are occurring in the postpartum period. Data from the Centers for Disease Control and Prevention confirm that roughly one-third of all pregnancy-related deaths occur one week to one year after a pregnancy ends. In some states, the number is much higher. In Illinois, for example, 56 percent of pregnancy-associated deaths occurred between 43 and 364 days postpartum. For women enrolled in Medicaid during—and on the basis of—pregnancy, the postpartum period can be particularly ominous for their health. Providing 12 months of continuous coverage after the end of pregnancy can help.
Medicaid Coverage For Pregnant Women
Low-income pregnant women are categorically eligible for Medicaid. At present, this coverage extends through the end of the month in which the 60-day period (beginning on the last day of her pregnancy) ends. Federal law requires all states to cover low-income pregnant women up to 138 percent of the federal poverty level, but states can extend coverage further. At present, every state except Idaho, Louisiana, Oklahoma, and South Dakota extend coverage beyond the federal minimum.
The benefits pregnant women receive through Medicaid will vary by state and eligibility pathway (that is, traditional Medicaid, pregnancy-related Medicaid, and Medicaid expansion). Traditional, full-scope Medicaid in all states provides comprehensive coverage, including prenatal care, labor and delivery, family planning services and supplies, and any other medically necessary services. Pregnancy-related Medicaid covers services “necessary for the health of a pregnant woman and fetus, or that have become necessary as a result of the woman having been pregnant.” States that have expanded Medicaid under the Affordable Care Act (ACA) are required to provide coverage through an alternative benefit plan (ABP). Notably, ABPs must cover the 10 essential health benefits, including maternity care, as well as family planning services and supplies, among other benefits. (Note: some states also provide coverage to low-income pregnant women through the Children’s Health Insurance Program [CHIP] and the unborn child option.)
Medicaid is the largest single payer of maternity care in US, covering 43 percent of all births in 2017. In some states, the share of births financed by Medicaid is much higher. As such, this program has a significant role to play in improving maternal health and helping to eliminate preventable maternal mortality.
The Need For Continuous Coverage Through 12 Months Postpartum
Despite the robust Medicaid coverage options for low-income pregnant women, gaps in coverage remain. This is especially true in the postpartum period. According to a 2005–13 analysis of the Medical Expenditure Panel Survey data, nearly 60 percent of pregnant women experienced a month-to-month change in insurance type during the nine months of pregnancy, and half were uninsured at some point in the six months following birth. This concept—known as “churn” or the cycling on, off, and between health insurance programs—is particularly pronounced in the perinatal period.
Indeed, recent findings on perinatal insurance churn post-ACA confirm that one in three women experienced a disruption in insurance coverage before, during, or after pregnancy, and nearly 60 percent of these perinatal insurance disruptions include a period of uninsurance. Perinatal insurance churn is prominent across states, regardless of Medicaid expansion status: Half of women in non-expansion states and nearly one in three women in Medicaid expansion states experience perinatal insurance disruptions.
With a growing number of maternal deaths occurring in the postpartum period, keeping women covered through Medicaid is critically important. In fact, research concludes that extending coverage improves health outcomes. Specifically, access to Medicaid expansion has been associated with 1.6 fewer maternal deaths per 100,000 women compared with states that didn’t expand the program. State maternal mortality review committees (MMRCs) are also touting the benefits of Medicaid to maternal health, and five states included the recommendation of providing continuous coverage in their most recent MMRC reports. The American College of Obstetricians and Gynecologists and its physician partners also recommend extending coverage. Moreover, the American Medical Association’s House of Delegates adopted a resolution supporting the extension of Medicaid coverage for women in the postpartum period at its June 2019 meeting.
This is the context in which state and federal policy makers have begun to propose extending Medicaid coverage to 12 months postpartum (exhibit 1).
State Efforts In 2019 To Provide 12 Months Of Continuous Coverage
To help curb maternal deaths in the postpartum period, medical and behavioral health conditions must be managed and treated before becoming progressively severe. Providing women with continuous access to health insurance is a critical first step. Specifically, extending Medicaid coverage for pregnant women from 60 days to 12 months postpartum would help women access the care they need to address health concerns well after their pregnancy ends. This may include care for a chronic condition such as diabetes or high blood pressure, treatment for a substance use disorder, or behavioral or other mental health services.
At present, there are two approaches states can take to implement an extension of postpartum coverage from 60 days to 12 months postpartum: through the use of state-only funds or through a Section 1115 waiver.
In 2019, several states took action to implement this policy (exhibit 1). For example, California Governor Gavin Newsom allocated $8.6 million to provide continuous coverage using state-only funds for women diagnosed with a maternal mental health condition (tentative implementation date of July 2020). Additionally, South Carolina became the first state in the nation to submit a Section 1115 waiver seeking federal authority (and matching funds) to implement continuous coverage for women enrolled in pregnancy-related Medicaid through 12 months postpartum. The Centers for Medicare and Medicaid Services (CMS) recently approved several elements of South Carolina’s request, but the 12 months postpartum provision was left out of the approval.
Exhibit 1: State efforts in 2019 to extend Medicaid coverage for pregnant women beyond 60 days postpartum
Source: Author’s analysis on behalf of the American College of Obstetricians and Gynecologists.
Federal Efforts In 2019 To Provide 12 Months Of Continuous Coverage
Several federal bills were introduced in 2019 to provide women with Medicaid-covered births with coverage through 12 months postpartum. Most notable is H.R. 4996—the Helping MOMS Act, sponsored by Congresswoman Robin Kelly (D-IL), which was reported to the full House on a bipartisan basis via a voice vote by the Energy and Commerce Committee on November 20, 2019. This legislation would create a state plan option to implement 12 months of postpartum coverage for women enrolled in Medicaid or CHIP. It would essentially make it easier for states to implement one year of continuous coverage for this population by allowing them to bypass the waiver process.
H.R. 4996 builds on the legislative success of the 118th Congress, which saw the Preventing Maternal Deaths Act of 2018 and the Improving Access to Maternity Care Act of 2018 signed into law. Giving states the option to provide new mothers with continuous coverage through one year after the end of pregnancy is the necessary next step Congress must take to improve maternal health for our nation’s most vulnerable.
Looking To 2020
Several states are planning legislative or regulatory action in 2020 to extend Medicaid coverage for postpartum women. Pennsylvania, for example, introduced legislation on December 9, 2019, for its 2020 legislative session. Similarly, on December 10, 2019, Virginia Governor Ralph Northam announced plans to invest “nearly $4 million over the biennium to extend this coverage up to one year post-pregnancy and include medically necessary treatment for addiction and substance use disorder.” Moreover, Missouri, New Jersey, and Illinois have Section 1115 waivers in the pipeline, and many more waivers are expected throughout the year. States are eager to implement this policy to help save women’s lives now. CMS must act by approving waivers as they come through for consideration.
And while Congress looks to tackle drug pricing and surprise billing—amidst a presidential election—in 2020, they can’t afford to leave moms behind. Women enrolled in Medicaid during pregnancy are dying. As recently noted by Kay Johnson, Sara Rosenbaum, and Morgan Handley, providing them with health insurance coverage is part of the solution. Creating the state plan option will help facilitate approval of state demonstrations at a faster rate.
Moms can’t wait. Let’s use every lever available—including state waiver authority and federal legislation—to make 2020 the year that postpartum women receive one year of continuous coverage after giving birth.