This article is part of a series exploring state efforts to ensure that people with OUD continue to receive treatment safely during the pandemic.
Between 1999 and 2014, opioid use disorder (OUD) among pregnant women more than quadrupled, risking the health of the women—before and after giving birth—and their infants. As states grapple with COVID-19’s exacerbation of the opioid crisis, several are taking innovative steps to address the needs of high-risk groups, including low-income, postpartum patients with OUD. Untreated maternal OUD can lead to placental abruption, low birth weight, or more severe neonatal abstinence syndrome (NAS), a withdrawal condition that occurs when a newborn is exposed to certain substances in utero, such as opioids.
The most effective treatment for this population is medication for OUD (MOUD), which is covered by Medicaid, the public health insurance program for low-income Americans. Although Medicaid has a special eligibility pathway for low-income pregnant and postpartum women, pregnancy-related coverage in many states ends at the federal minimum requirement of 60 days postpartum, making mothers with OUD more vulnerable to overdose—and highlighting the need to extend coverage for this vulnerable group.
Many pregnant women with OUD have or are eligible for Medicaid. In 2014 (the most recent year for which data is available), the program also covered more than 80% of infants with NAS. Consistent health insurance coverage is key to continuity of care, MOUD maintenance, and reducing risk of overdose. Yet cycling between insurance statuses is common right after giving birth: From 2015-17, for example, 28.7% of women experienced a disruption in insurance from delivery through the postpartum period.
Although MOUD is the best therapy available for pregnant and postpartum patients with OUD, few treatment programs cater to this population, and as of 2014, only half of pregnant patients in publicly funded treatment received MOUD. This is especially concerning because overdose risk heightens postpartum, with a 2012-14 study from Massachusetts showing that the highest level of risk occurs seven to 12 months after delivery.
To help address this problem, the American College of Obstetricians and Gynecologists and the American Medical Association recommend that states extend pregnant beneficiaries’ Medicaid up to 12 months postpartum. The Medicaid and CHIP Payment and Access Commission, a nonpartisan legislative branch agency, also signaled during its October 2020 meeting that it would recommend extending Medicaid to one year postpartum.
Extended Medicaid coverage could also mean broader access to methadone and buprenorphine, two FDA-approved forms of MOUD. Initiating and maintaining patients on these medications produces better maternal health outcomes than supervised withdrawal from opioids, which is more likely to lead to relapse or overdose.
On March 18, 2020, Congress passed the Families First Coronavirus Response Act, which prohibits states from ending coverage for Medicaid beneficiaries, including postpartum individuals, during the public health emergency. It provides enhanced federal funding to states to continue coverage for postpartum Medicaid beneficiaries and other eligibility groups; some states have even moved to permanently extend benefits to 12 months after the public health emergency declaration ends. Nineteen states and Washington, D.C., either introduced bills or enacted laws on the issue, several of them during the pandemic.
Even before the pandemic, certain states had started to recognize the needs of low-income pregnant and postpartum women by expanding Medicaid through Section 1115 waivers, which allow states to test new approaches to improve their programs. South Carolina was the first state to gain approval for this reform from the U.S. Centers for Medicare & Medicaid Services in December 2019; Illinois, New Jersey, Missouri, and Tennessee have also sought approval to lengthen coverage. In the fall of 2020, Indiana applied for an 1115 waiver and D.C. passed the Postpartum Coverage Expansion Amendment Act of 2020, which requires the mayor to apply for a waiver that will extend pregnancy-related Medicaid coverage to one year after delivery.
For many states, this year has marked the first time that postpartum beneficiaries have been able to maintain health coverage for the length of time recommended by nearly 300 health and advocacy organizations. Although postpartum Medicaid extension is a necessary step to reform OUD care, it is not a panacea. States must continue to improve access to health care and treatment services for their pregnant and postpartum residents and expand access to MOUD to prevent opioid-related deaths in this population.
Beth Connolly is director and Kamren Gilbard is an associate with Pew’s substance use prevention and treatment initiative.