The Biden administration is making a major push to expand Medicaid coverage for new mothers from two months to a full year in an effort to address a shocking reality: the United States has the highest rate of pregnancy-related deaths of any industrialized nation.
Starting in the spring, states have the option to expand Medicaid postpartum benefits over the next five years as part of the American Rescue Plan enacted in March. Money for further expansion is included in the Democrats’ other big legislative priority, the social safety net and climate change bill known as Build Back Better.
Lawmakers are confident that extending postpartum Medicaid coverage to 12 months will significantly reduce maternal mortality rates. But experts and advocates warn that change still won’t be enough to ensure lower-income mothers have access to health insurance after that year of postpartum coverage is up.
“The policy is basically kicking the problem just down the road from two months to 12 months,” said Jamie Daw, an assistant professor at Columbia University who researches health policy.
The majority of pregnancy-related deaths happen during delivery and up to one year afterward, according to the Century Foundation, an independent think tank. But in many states, Medicaid currently provides pregnancy-related coverage to mothers of newborns for only 60 days after giving birth. So they must either qualify for Medicaid through a different pathway, get insurance on their own if they can afford it, or risk going without any coverage at all, meaning they may not be able to access care for lingering health complications from their pregnancy.
Postpartum care covers a wide range of needs, such as following up on pregnancy complications, managing chronic conditions such as diabetes and hypertension , accessing family planning resources, and addressing mental health. Although the postpartum period traditionally was considered to last six to eight weeks, the more recent thinking in medicine is that mothers need continuous care for at least a year following childbirth.
The legislation would invest $3 billion in maternal health services, including expanded Medicaid funding, which would give an estimated 1.2 million mothers year-long postpartum coverage over the next decade.
“In the United States of America, in the 21st century, being pregnant and giving birth should not carry such great risk,” Vice President Kamala Harris said in kicking off the White House’s Maternal Health Call to Action Summit on Tuesday. “Mothers are the backbone of our economy, and their children are the future of our economy. We know that when women do not get the health care they need, families suffer, communities suffer, and our nation suffers.”
The Medicaid expansion also strives to address a stark racial disparity — women of color have much higher maternal mortality rates and make up a large share of Medicaid enrollees. Black and American Indian/Alaska Native mothers had the greatest mortality rates of any racial groups, and were two to three times more likely to die from pregnancy-related causes than white women, according to a report from the Georgetown University Health Policy Institute. It cited structural racism in the health care system and limited access to maternal care services among the factors.
“Failure really is not an option here. This is a crisis,” said Representative Ayanna Pressley, a Boston Democrat who has led a push in Congress for increased access to maternal care, particularly for Black mothers. “We are making those investments that meet the level of scale that this crisis is. So this is a matter of health care justice. It is a matter of racial justice. And I’m confident that we will get this done.”
Medicaid, a joint federal and state program, currently provides postpartum care for 60 days, but coverage varies from state to state. The 2010 Affordable Care Act gave states the option to expand Medicaid eligibility to cover more low-income Americans. Many have, but 12 mainly Republican-led states, including Texas, Georgia, Alabama, and Tennessee, have not, and the percentage of mothers with postpartum coverage whose births are covered by Medicaid often is lower in those states.
Mothers there are more likely to fall into a coverage gap where their income is too high for Medicaid and they also don’t qualify for subsidized health insurance premiums, according to the Kaiser Family Foundation.
“The question is, what happens to somebody who’s had a Medicaid-funded birth?” said Usha Ranji, the Kaiser Foundation’s associate director for women’s health policy. “Do they get health coverage after that time? That really is heavily dependent on state policy choices.”
States that expanded Medicaid eligibility often have other options for coverage for those who don’t qualify. Massachusetts had the nation’s lowest percentage of mothers who lack postpartum coverage after giving birth to a child covered by Medicaid, at 1.7 percent, according to data complied by Daw, the Columbia professor, while Texas had the highest at 56.7 percent. This may be because Massachusetts residents who don’t qualify for Medicaid are usually eligible for a state-run private health insurance exchange with no premiums.
The American Rescue Plan’s provisions are designed to encourage the 12 states that have not expanded Medicaid to come on board. That would expand health care coverage more broadly to more than 2 million people who currently fall into the coverage gap — not just mothers.
Many of those 12 states have committed to increasing Medicaid postpartum coverage starting in April, when the new option to extend Medicaid would take effect. But not all plan to offer one year of coverage; Texas and Georgia, for example, have agreed to increase postpartum coverage to six months.
If the Build Back Better Act passes, all states would be required to offer one year of postpartum coverage to Medicaid recipients, so mothers would have consistent access to benefits regardless of their ZIP code.
The bill also includes provisions to help people, including parents, who fall into the coverage gap, by extending tax credits so they can purchase private coverage under the ACA with no premiums. But this is a temporary fix that would only stay in place through 2025.
“It’s really important for people to realize that full Medicaid expansion plus this postpartum extension work together to provide people coverage across their reproductive lifespan,” Ranji said.
The proposed measures likely aren’t a blanket solution to persistent gaps in maternal care. The Georgetown report found that there still are racial disparities in maternal mortality rates between states that expanded Medicaid eligibility and those that didn’t.
Daw said that the easiest way to address those disparities would be to further expand Medicaid coverage so that mothers could access continuous care before, during, and after pregnancy.
“Ultimately, the goal would be to ensure that all people, including birthing people and reproductive-aged women, have access to insurance throughout their life,” Daw said, “not just when they’re pregnant or when they’re postpartum.”
Neya Thanikachalam can be reached at firstname.lastname@example.org.