The central premise is straightforward enough, and commonsensical: women who have better access to health care are less likely to have children who die soon after birth. So, since North Carolina’s infant-death rate is unnervingly high—thirty-ninth in the country—the state should expand access to health care for women of reproductive age.

“Essentially, our argument is that research has already shown that mothers who have access to prenatal care are less likely to experience infant mortality,” says NC Child research director Whitney Tucker. “If we’re able to provide more health care, we’re likely to see those infant- and fetal-mortality rates go down.”

Last week, the child-advocacy organization released a report, coauthored by Tucker, grimly titled “Giving Birth in North Carolina Is Still a Risky Business.” It lays out precisely that case: too many North Carolina women lack access to health care, but the state can remedy that by expanding Medicaid.

And it’s not just infant mortality NC Child is worried about. To Tucker, the report’s most jarring finding is that, while North Carolina’s infant-death rate is still frustratingly high at 7.2 per one thousand live births, nearly as many children experienced fetal death (818)—meaning they perished after twenty weeks of gestation, which is commonly known as stillbirth—as infant death (873) in 2016. (The national infant-death rate is 5.8 per one thousand live births, which itself is higher than that of most developed countries.)

The number of fetal deaths, the report notes, “has ranged from 753 to 895 per year over the past decade, and the fetal mortality rate fluctuated very little in the state between 2007 and 2013. The rate rose sharply between 2014 and 2015 and fell in 2016, but has yet to decline past 2007 levels despite increased statewide interest and investment in infant and maternal health.”

It’s hard to get a sense of where North Carolina ranks in fetal deaths, as not all states maintain analogous records. But it’s not hard to see the racial disparities at play: while the state’s fetal death rate was 5.2 per one thousand live births from 2012–16, it was more than twice that—12 per one thousand—for African Americans.

For both fetal and infant deaths, the underlying problems are the same. “Fetal and infant health is directly tied to maternal health status preconception and during the gestational period,” the NC Child report says. “Nearly half of the primary causes of infant mortality in North Carolina … have been linked to maternal risk factors occurring prior to pregnancy. Similarly, while direct causes of fetal mortality are less understood in most cases, studies have also found maternal health conditions to be leading risk factors for fetal death.”

And underlying that is the fact that, in North Carolina, one in five women of reproductive age does not have health insurance. According to the report: “Uninsured women are less likely than their insured peers to receive treatment or counseling for a variety of pregnancy risk factors, including mental health concerns and the physical health conditions referenced earlier in this report. Uninsured adults are twice as likely as their insured peers to forgo seeing a doctor when they are sick, and are less likely to receive services to help them manage chronic disease or major health conditions.”

There are state resources available to lower-income pregnant women; the Medicaid for Pregnant Women program covers women who earn up to 196 percent of the federal poverty line, or about $48,000 for a family of four. In fact, Medicaid covers 54 percent of all births in North Carolina, according to NC Child.

“While Medicaid for Pregnant Women is a critical program,” the report says, “it is insufficient in providing all of the preconception and early pregnancy coverage women need to promote healthy pregnancies.”

The answer, the report argues, is to expand Medicaid under the Affordable Care Act, which would give health care access to an estimated half-million North Carolinians. Currently, 43 percent of the state’s nonelderly uninsured adult women fall into what is known as the coverage gap—meaning they earn too much to qualify for Medicaid but not enough to obtain insurance subsidies through the Affordable Care Act’s marketplace.

Indeed, a recent study in the American Journal of Public Health found that infant mortality declined more in states that had expanded Medicaid than in those that did not, “with greater declines among African-American infants”—which, as NC Child points out, is a particularly vulnerable population in North Carolina.

But if the solution is obvious to NC Child, it hasn’t been to the General Assembly, which has steadfastly refused to expand Medicaid; in 2013, legislators even passed a law explicitly forbidding it. Democrats have pointed out that the state is leaving billions of dollars on the table, since under the ACA, the federal government picks up about 90 percent of the expansion tab.

From 2013–22, according to a 2014 report from the Urban Institute, the state would have had to cough up about $300 million a year, in exchange for $3.9 billion a year in federal funding and another billion in hospital reimbursements.

When Governor Cooper took office in the waning days of the Obama administration, he made noise about unilaterally expanding the program, which prompted a lawsuit by House Speaker Tim Moore and Senate leader Phil Berger. Cooper never followed through, however, so the lawsuit was dropped.

But then, last month, the Trump administration changed the equation: it began allowing states to impose work requirements on able-bodied Medicaid recipients, something Republicans have long sought to do.

Cooper sought a waiver to the work-requirement provision in November, but the requirements would only apply if the state expanded Medicaid, and then only to the people in the expanded Medicaid program. It was an olive branch. So far, legislative leaders haven’t accepted it.

There are good reasons to be skeptical of work requirements. As the NC Child report points out, health problems are often a reason people are unemployed; according to a recent study in Michigan, 75 percent of out-of-work Medicaid recipients had a chronic health condition, which would seem to indicate that work requirements are a solution to a problem that doesn’t really exist.

But even so, advocates say, expansion is worth it.

A bill filed last year in the legislature—HB 662—would expand Medicaid while imposing work requirements and a premium of 2 percent of household income. But what separates it from previous failed attempts to expand Medicaid is that its four primary sponsors are Republicans.

“I do think having four Republicans as primary sponsors on there helps,” says Wake County Democratic state representative Duane Hall, a cosponsor. He’s supported Medicaid expansion since he joined the state House and has cosponsored straight Medicaid-expansion bills that went nowhere.

He adds: “Our failure to expand Medicaid is the biggest disappointment I’ve had since I’ve been in the legislature.”

Whether that means HB 662 will see movement once the short session convenes in May is anyone’s guess.

After all, Hall told the INDY Thursday—the day the Republicans unveiled a class-size mandate reprieve that would also take control of an Atlantic Coast Pipeline mitigation fund and reestablish a bipartisan State Board of Elections that has twice been rejected by state courts—”You’re asking a Democrat who didn’t know what was on the floor before it was on the floor.”

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North Carolina Has One of the Country’s Highest Infant-Death Rates. Expanding Medicaid Could Change That.