If not for Medicaid coverage, Claire Brown doesn’t think she would have gotten the help that may have saved her life. Nine months after her third child’s birth, Brown realized she had descended into a deep depression. She struggled with “the basics,” like getting out of bed, cooking meals and folding laundry. “It seemed like the tiniest thing could really suddenly make me feel really stressed,” Brown said.
She recognized she was in trouble and told her husband, who was pursuing his doctoral degree. “It was like an S.O.S,” said Brown, who is now 32 and lives in Chapel Hill, North Carolina.
She received six days of intensive therapy and counseling in a psychiatric unit. She met with a doctor and was prescribed different medication to treat her depression, and has taken part in weekly therapy sessions ever since.
Brown, who qualified for Medicaid based on income, said she knows that the cost of the postpartum mental health care she needed could have easily “added up,” but because of her coverage, she “didn’t have to worry about these exorbitant doctor bills.”
Starting this month, more people may get the same experience. A new provision guarantees access to health care via Medicaid for residents of some states during one of the most vulnerable times in their lives – the months following childbirth.
Four out of 10 births in the U.S. are paid for by Medicaid, the public health insurance program that covers nearly 79 million people nationwide. Women who are normally disqualified from Medicaid because of an income cut-off but don’t make enough to afford other insurance are granted special eligibility during pregnancy and the postpartum period. Prior to the COVID-19 pandemic, most people who gave birth under Medicaid lost their coverage 60 days after delivery, if they didn’t otherwise qualify to stay in the program. This is especially true in the 12 states that have not expanded Medicaid under the Affordable Care Act. But when the Trump administration declared the coronavirus a public health emergency, people on Medicaid received continuous coverage, so they did not have to worry about re-enrolling or potentially losing their health insurance in the middle of the pandemic.
The benefits of that unprecedented extension of coverage may have laid the groundwork for more lasting effects. Congress made sure more generous postpartum benefits – 12 months of health coverage under Medicaid and the Children’s Health Insurance Program – would be available under the American Rescue Plan last year, and the Centers for Medicare and Medicaid Services offered guidance to states about this option in December. The extension, which kicked in April 1, has made an estimated 720,000 pregnant and postpartum people eligible to receive those benefits.
This option to extend coverage lasts for five years, but to tap into it, states must amend their Medicaid plans and get federal approval. So far, 15 states and the District of Columbia, including North Carolina where Brown lives, have enacted legislation or submitted waivers to seek that sign-off. Five states – Illinois, Missouri, New Jersey, Virginia and Georgia – have formally submitted waivers and been approved.
Among the states that have moved toward extended access to Medicaid, benefits can vary. In California, people suffering from postpartum depression qualify for a full year of Medicaid after delivery under legislation that has not yet received federal approval. In Georgia, the coverage window extends from 60 days to six months after delivery.
“This policy catches women during a vulnerable time,” said Dr. Sarah Gordon, an assistant professor of health law, policy and outcomes at Boston University.
Recent research has shown that as many as a third of women experience a change in health insurance from the time they become pregnant until after they deliver, according to federal data. Disruptions like losing health care coverage or not having consistent access to a primary care provider can lead to worse health outcomes, including preventable death, Gordon said, such as when dire health conditions slip through the cracks undetected.
“If I was in a situation where I didn’t know if my insurance would cover it, I don’t think I would have gotten that care,” Brown said.
Improving “outcomes for two generations”
The United States has distinguished itself as one of the worst developed nations for support of pregnancy and birth. In 2020, 861 women died as a result of pregnancy in the U.S., the Centers for Disease Control and Prevention reported, up from 754 women the previous year. The maternal mortality rate is 23.8 per 100,000 live births, more than three times the rate reported in Germany or the United Kingdom. And while maternal mortality decreased around the world between 2000 and 2017, it actually ticked upward in the U.S. during the same period.
These tragic statistics are worse in Black and brown communities, and are a grim reminder of the influence of systemic racism in U.S. health care. Black women have died due to pregnancy and childbirth at disproportionate rates for years, steadily increasing since 2018. In 2020, Black women accounted for 55.3 pregnancy-related deaths per 100,000 live births – nearly three times the rate of white women, according to the CDC.
“Pregnancy and childbirth should be a dignified, safe, and joyful experience for all,” President Joe Biden said in an April 8 written proclamation marking Black Maternal Health Week. “For far too many mothers, however, complications related to pregnancy, childbirth, and postpartum can lead to devastating health outcomes — including hundreds of deaths each year.”
More than half of pregnancy-linked deaths happen during the first year after delivery, according to research from the Commonwealth Fund. And mental health conditions, including postpartum depression, death by suicide and fatal drug overdose, are among the leading underlying causes of maternal mortality starting roughly six weeks after childbirth. Prior to this benefit extension, millions of people lost Medicaid coverage while their bodies were still actively healing from carrying and delivering newborns.
For years, data and research has laid out with increasing clarity how the American health care system and society as a whole largely abandons caregivers and their infants. A patient might be diagnosed with postpartum depression, start treatment, “and then have pregnancy Medicaid coverage just disappear,” said Samantha Meltzer-Brody, a psychiatrist at the University of North Carolina at Chapel Hill who also directs the UNC Center for Women’s Mood Disorders. “And that’s just terrible.”
Prior to the pandemic, states that expanded Medicaid reported lower maternal mortality rates than non-expansion states, a February 2020 study suggested. That was especially true among Black people. But COVID made it virtually impossible to ignore those conditions, she said, and this extension of postpartum benefits “reflects a sea change.”
“We’ll be able to continue to treat women and hope they get well,” she said. “That’s going to be good for mom and good for the baby. You’re helping to improve health outcomes for two generations.”
Making postpartum health care more accessible and affordable is a step toward “preparing the next generation” and tackling a problem that has been “festering for way too long,” said Health Secretary Xavier Becerra on March 28 during a news conference. “It’s outrageous that in the wealthiest country in the world, we still have women who are dying after giving birth.”
What happens when help runs out
In May 2019, Katrina Percell gave birth to a healthy baby boy, but she struggled to maintain her own mental well-being. While pregnant, Percell said she “started having bad thoughts.”
She reached out to her doctor, who listened to her and connected her with a psychiatrist. Her pregnancy and delivery qualified Percell for Medicaid, which paid for her medication treatment and cognitive therapy to help her manage her anxiety and depression. Throughout her life, Percell said both conditions had gone untreated up until that point. But her coverage only lasted six weeks, she said, “enough time to have my six-weeks postpartum check-up.”
More than a year later, in September 2020, Percell found out she was pregnant again. After that child was born in May 2021,she was able to keep her Medicaid benefits under the public health emergency and resume her mental health treatment and therapy. She found prescriptions that yielded better results for her – paying $3 for a month’s worth of potentially life-saving medication. If she needed dental work, she could get it.
“I’ve been stress-free,” she said. “I’ve been able to get things done.”
An assistant teacher by training and single mother raising three young children, Percell, 31, said times have remained tough. She works part-time in a fast-food restaurant to earn extra money and lives with her parents, sharing a single bed with her children: “It’s pretty tight.”
A few weeks ago, she received a letter saying her Medicaid benefits would be cut off next month, shortly after her youngest child’s first birthday. Her mental health pays little heed to calendar dates, even with North Carolina’s extension. While she had Medicaid for a calendar year after giving birth to her third child, Percell still struggles with insurance churn and how it complicates her access to the mental health care she needs for herself and her family.
“If I don’t get Medicaid again, I’m not going to be able to take my medicine,” Percell said. “I’m not going to be able to afford it.”