Postpartum Medicaid expansion is the first step to maternal health equity, experts say
Short-term Medicaid coverage can exacerbate health problems for new mothers, adding to the health issues and stress some face, says Maggie Clark, program director at the Georgetown University Center for Women and Families. (Getty Images)
Arkansas has the highest maternal mortality rate in the United States: 43.5 deaths from 2018 to 2021 for every 100,000 live births, according to the latest federal data. But the state only extends postpartum Medicaid to 60 days after childbirth.
A bill by Arkansas Rep. Aaron Pilkington, R-Knoxville, aims to change that and would seek to continue Medicaid coverage postpartum for a full year. The House Public Health, Welfare and Labor Committee heard the measure Tuesday, but Pilkington told States Newsroom he is optimistic the bill will become law.
Extending health care benefits for low-income people with infants could reduce maternal mortality rates in the U.S., several reproductive health experts told States Newsroom. But researchers also said it’s too soon to determine if those extensions will lessen maternal deaths in a nation where 13 states ban abortions with few exceptions, and the laws are so vaguely written in some cases that medical professionals are wary of providing life-saving health care.
What’s clear is that U.S. maternal mortality rates keep growing, an anomaly compared to other economically similar countries. In 2021, the nation’s rate was 32.9 deaths per 100,000 live births, up from 23.8 deaths per 100,000 live births in 2019, according to data released this month from the Centers for Disease Control and Prevention’s National Center for Health Statistics. In other words, 1,205 women died of maternal causes in the U.S. during the second year of the COVID-19 pandemic, up from 861 maternal deaths in 2020 and 754 maternal deaths in 2019. The CDC categorizes a death as maternal if it occurs during pregnancy, childbirth or up to 42 days postpartum.
The CDC data also illuminates racial disparities: The maternal mortality rate for Black women was 69.9 per 100,000 live births, 2.6 times the rate for non-Hispanic white women, which was 26.6 in 2021. The maternal mortality rate for Hispanic women that year was 28.
“These are sad and unfortunate, but not surprising,” said Dr. Maeve Wallace, a reproductive epidemiologist at Tulane University’s Mary Amelia Center for Women's Health Equity Research in Louisiana.
“From what we know about the coronavirus pandemic, we probably could’ve seen that maternal health would’ve been impacted negatively, both directly by the virus and indirectly by all of the social and economic disruptions that it caused, and especially how uneven the economic impact was across the population, really exacerbating what already was long-standing and entrenched racial inequities in maternal health,” Wallace said.
Some states weigh expansion
Under the federal coronavirus pandemic emergency plan that President Joe Biden signed into law in March 2021, states were allowed to apply for 12-month postpartum Medicaid coverage. As of March 23, the Centers for Medicare and Medicaid Services has approved expansions for 30 states and Washington, D.C.
Nine states are waiting on approval from the federal agency: Arizona, Delaware, Mississippi, New York, Rhode Island, South Dakota, Vermont, Utah and Wyoming.
Mississippi is the latest state to expand Medicaid from the federally mandated 60 days to 12 months postpartum, according to Mississippi Today. Republican Gov. Tate Reeves signed a bill into law this month after overcoming his own skepticism of the proposal. For years, the state Senate has supported postpartum Medicaid expansion, only for the initiative to stall in the state House, as Mississippi Today has chronicled.
Of the 11 states that have yet to expand Medicaid coverage — Alaska, Arkansas, Idaho, Iowa, Missouri, Montana, Nebraska, Nevada, New Hampshire, Texas and Wisconsin — to a year for new mothers, eight have pending legislation that would extend coverage from 60 days to 12 months, according to a States Newsroom analysis.
The Missouri Senate cleared postpartum Medicaid expansion earlier this month. In Montana, the House recently voted to extend postpartum Medicaid coverage from 60 days to a year as an amendment tucked in the state budget bill; the proposal is pending in the upper chamber. Three states that have relatively wide abortion access, Alaska, Nevada and New Hampshire, have also introduced related bills this year.
In Texas, Democratic Rep. Toni Rose has sponsored a bill to extend postpartum coverage to a year, the Texas Tribune reports. The House Health Care Reform Select Committee heard the bill this month. In February, House Speaker Dade Phelan, a Republican, indicated support for the extension, along with repealing taxes on diapers and menstrual products. (The Texas House approved the latter proposal Tuesday.)
As of mid-March, new mothers in Wisconsin would be eligible for Medicaid for three months postpartum upon federal approval; a 12-month expansion bill is pending in the Legislature. The states with near-total abortion bans typically have higher maternal mortality rates, but Wisconsin is an outlier: In 2021, its rate was 11.6 maternal deaths, one of the lowest rates in the country, according to CDC data. But the 2021 data predates the bans enacted after the U.S. Supreme Court overturned the constitutional right to an abortion last year.
Why postpartum Medicaid matters post-Dobbs
People in states with abortion bans are up to three times more likely to die during pregnancy, childbirth or postpartum, according to a Gender Equity Policy Institute report released in January.
Postpartum Medicaid expansion for new mothers is a first step to maternal health equity, not a catch-all solution, said Maggie Clark, program director at the Georgetown University Center for Women and Families in Washington, D.C.
"While promising, a longer coverage period does not itself lead to improved outcomes,” Clark wrote in a brief released last week. “States should take a closer look at the benefit and payment levers available in Medicaid to ensure that the longer coverage period translates to better access to needed care for mothers and infants in the postpartum year.”
Maternal health care needs an overhaul, Clark said in an interview. Childbirth can lead to myriad health conditions, including diabetes, hypertension, substance abuse and mental health issues: think depression, anxiety or psychosis, Clark said. Short-term Medicaid coverage can exacerbate health problems for new mothers, she said.
“When someone loses their health coverage when they’re dealing with all of that, that means they lose access to prescriptions, they lose access to the doctor that’s supporting them through that time,” Clark said.
Lawmakers in Congress have taken steps to address the maternal death crisis. North Carolina Rep. Alma Adams and Illinois Rep. Lauren Underwood, both Democrats, will reintroduce the Black Maternal Health Momnibus Act this session, according to Sam Spencer, a spokesperson for Adams.
“Demographics should not determine your destiny, but it’s going to take addressing social determinants of health – from poverty to education to transportation and environmental factors – to save lives,” Adams said in a statement to States Newsroom. She added that the bill is nonpartisan.
The collection of bills aim to overhaul the perinatal workforce, improve data collection related to maternal health and provide funding to reproductive health community-based organizations, among other proposals. In 2021, President Joe Biden signed a “momnibus” bill into law that gave $15 million to the U.S. Department of Veteran Affairs to support maternal health, The 19th reported.
U.S. Sens. Tim Kaine, D-Va., and Lisa Murkowski, R-Alaska, reintroduced the Mothers and Newborns Success Act, a related bill that aims to increase data collection of maternal and infant health issues, last week.
Reproductive health experts across the country, especially those in the South, a region with high maternal mortality rates and the most abortion bans, agreed that the full spectrum of maternal health care needs improvement.
“Increasing the number of perinatal health care workers who can look like the people they’re serving is definitely a solution so that they can improve maternal health outcomes because they can improve culturally congruent care,” said Laneceya Russ, the Louisiana-based executive director of March for Moms, a national maternal health advocacy group.
For Wallace, the Tulane epidemiologist, “it’s been disturbing to watch the closure of birthing centers and other maternity care opportunities in rural places across the country.” Repealing collaborative practice agreements between physicians and assisting health care providers, such as nurse practitioners, could help expand midwifery care and address staff shortages in maternity care, Wallace said.
Dr. Natalie Hernandez, executive director of the Morehouse School for Medicine’s Center for Maternal Health Equity in Georgia, recently examined the effects of COVID-19 on maternal health outcomes. Like Russ, she agreed diversifying the perinatal workforce, along with increasing doula care in communities of color – for example, some states are moving to create doula Medicaid reimbursement programs – could also help improve birth outcomes.
“A lot of solutions have been focused on the clinical aspects, but we need to ensure we’re adjusting those nonclinical causes – the majority of what contributes to our health status is not just access to care, but it’s really the social determinants of health,” she said. “Then we’ll get better care.”
Kelcie Moseley-Morris contributed reporting.