States look to Medicaid to curb maternal mortality

For many, expecting a baby is a dream come true. Pregnancy conjures images of baby showers and gender reveal parties, Facebook-worthy photos and a nursery filled with colorful toys and children’s books.

But pregnancy and childbirth can have complications too. From delivery issues like hemorrhaging, torn muscles and other injuries sustained during and after birth, many women find themselves in need of additional health care and services long after giving birth. 

While the Medicaid program has historically covered pregnancy-related health needs, coverage only lasts60 days postpartum. That was the case until a 2021 provision under the American Rescue Plan Act allowed states to extend the coverage period to 12 months through a state plan amendment. The extension option, slated to sunset after five years,was made permanent under last year’s passage of the Consolidated Appropriations Act. 

The state plan amendment option gave states a “much easier” pathway to expand coverage, said Taylor Platt, health policy manager at the American College of Obstetricians and Gynecologists. “I think that’s one of the reasons why from 2021 and onward, we’ve seen more and more states take up the option.” 

In fact, 49 states have moved to lengthen postpartum coverage under Medicaid, which finances four in 10 births across the nation. Even states that have not expanded Medicaid under the Affordable Care Act, such as Alabama, Mississippi and Texas, have extended postpartum care coverage. 

State Medicaid agencies have potential to see cost savings under this model, Platt said. Increasing access to preventative postpartum services can reduce the need for emergency room visits from the many patients who avoid routine health care to cut down on medical expenses. 

Montana’s Medicaid postpartum coverage, for instance, includes depression screening for caregivers, among other recommended procedures for pregnancy-related care, said Laurie Zephyrin, senior vice president for Advancing Health Equity at the Commonwealth Fund. Montana received federal approval for its state amendment plan late last year.

Plus, postpartum services apply to a small section of the overall population, “so it’s relatively low cost compared to Medicaid budgets overall,” said Edwin Park, research professor at Georgetown University’s McCourt School of Public Policy.

Idaho is the latest state to increase Medicaid pregnancy-related coverage to a full year with the March 25 passage of House Bill 633, which takes effect July 1. That leaves Arkansas as the sole holdout state. From 2018 to 2020, Arkansas had the highest maternal mortality rate in the U.S. 

During a roundtable of policymakers last month, Arkansas Gov. Sarah Huckabee Sanders said Medicaid postpartum coverage extension is unnecessary because alternative insurance options exist for individuals, such as fee-for-service Medicaid, the state’s ARHOME Medicaid expansion program or subsidized health plans from the federal health care marketplace, the Arkansas Advocate reported.  

Maternal health overall is receiving increased attention in a post-Dobbs world, Park said, “which I think is affecting how policymakers are viewing the postpartum [coverage] option, particularly in more conservative states that have had some of the most onerous restrictions on abortion.”

“I also think that because maternal mortality rates are steadily increasing in the United States, with really stark racial differences among Black and indigenous birthing people, [postpartum coverage expansion] has become a forefront when looking at health policy,” Platt said. “State lawmakers want to try and find ways to solve the maternal mortality crisis.” 

Indeed, the U.S. maternal mortality rate grew from 17.4 per 100,000 live births in 2018 to 23.8 in 2021. For Black women, the mortality rate was more than double (69.9 per 100,000 live births) that of white women (26.6 per 100,000 live births) in 2021. 

Maternal health can remain compromised for weeks, even months after delivery as well. Issues like postpartum depression, digestive problems and pain or infection can surface long after childbirth, so extending Medicaid coverage from 60 days to 12 months “is key to accessing service,” Platt said. “When you have coverage, and especially in the Medicaid population, you’re more likely to seek care, especially preventative care.” 

Whether an individual wants to see a primary care physician, a cardiologist or seek behavioral health services, for instance, “having that insurance coverage is key … to address [postpartum] issues from the ground up, instead of waiting until an emergent situation,” Platt said. 

“Coverage before, during and beyond pregnancy is really important for addressing the whole continuum of care,” Zephyrin said. While there is a cost to expanding Medicaid services, “there is a cost to not being able to access care,” she said. “There is a cost to mortality.”