More states are moving to extend Medicaid benefits to new mothers up to a full year after giving birth, far beyond the 60 days required by federal law.
That development, promoted by numerous medical groups as well as official state medical boards that focus on maternal health, reflects increasing alarm over the United States’ maternal mortality rate, which is the worst among developed nations and is trending in the wrong direction. There also is a growing awareness that women face increased health risks not only during pregnancy and labor and delivery, but also for months afterward. Nearly a quarter of postpartum-related deaths occur six weeks to a year after the end of a pregnancy.
States’ moves have been somewhat bipartisan, with Republicans supporting the expansion in some cases. And now the Biden administration is bolstering states’ efforts through a provision in the COVID-19 relief package that President Joe Biden signed in March—making it more likely that states will quickly win approval for the requested changes.
Last month, Illinois became the first state to receive a waiver from the federal Centers for Medicare and Medicaid Services, allowing it to continue providing Medicaid benefits to women from 60 days to a year after delivery (or the end of their pregnancies). Medicaid is the public health plan for low-income Americans.
Georgia and Missouri both won similar approvals, though Georgia’s extension only goes to six months and Missouri’s only provides for substance use disorder treatment in the extended period. (States must receive waivers from CMS to depart from normal Medicaid requirements.)
Indiana and New Jersey submitted applications last year, and Massachusetts, Washington state, Washington, D.C., and Virginia each are expected to submit theirs shortly, all seeking to extend postpartum Medicaid benefits beyond 60 days. Legislatures in other states also are considering measures that would result in similar applications. Some proposals are more restrictive than others, either in duration of benefits or the breadth of populations targeted.
“We believe that allowing women to maintain Medicaid coverage for a longer period during this vulnerable time is likely to improve access to and continuity of care, ultimately leading to improvements in experience of care and outcomes, along with potential reductions in future expenditures,” New Jersey wrote in its application to CMS.
The effort has drawn support not only from Democrats; some Republicans, too, have initiated measures.
In Mississippi, for example, the Senate bill that would extend Medicaid postpartum benefits was sponsored by Republican state Sen. Kevin Blackwell, chair of the Senate Medicaid Committee. But Republican members of a conference committee killed it in a procedural maneuver.
“Their fear was that it was going to expand Medicaid,” said Blackwell, who said he planned to reintroduce the measure next year.
Illinois submitted its application in January 2020, but it didn’t receive approval until the new administration took office.
“There were multiple [waiver applications] during the Trump administration, and essentially CMS just sat on that,” said Jamie Daw, an assistant professor at Columbia University’s Mailman School of Public Health who has done extensive research on perinatal insurance coverage for low-income women. “We can infer that what wasn’t a priority for the Trump administration is for the Biden administration.”
Biden provided further encouragement to the states to extend postpartum Medicaid benefits. The American Rescue Plan, the president’s COVID-19 relief package, includes a provision that enables states to extend postpartum benefits through an administrative action that is much faster and less cumbersome than using the waiver process, which can take months or even years.
Many who work in maternal health applauded the move. “Our approach to the states is to say however you can get it done, just go for it because the federal government has signaled there’s no wrong door to achieving this policy change,” said Emily Eckert, manager of health policy at the American College of Obstetricians and Gynecologists.
U.S. Sen. Dick Durbin and Rep. Robin Kelly, both Democrats from Illinois, want to go further. They introduced measures in Congress this year that would require all state Medicaid agencies to provide a year of postpartum coverage. They also want the federal government to pick up all the costs rather than requiring states to pay a share, as is the case with most Medicaid expenses.
Although neither the administration nor Congress has yet gone that far, maternal health care practitioners are enthusiastic over the progress they have made.
“Of all the things I have worked on in 30 years as an advocate, this will be the most impactful for our patients,” said Dr. Maura Quinlan, an OB-GYN with Northwestern Medical Group in Chicago. “I literally every day see women dropping out of care,” when they hit the 60-day mark.
Maternal Deaths after 60 Days
According to the federal Centers for Disease Control and Prevention, nearly 23% of pregnancy-related deaths after the day of delivery occur in the period between six weeks after delivery and the end of the first year.
Yet for most pregnant women who receive health coverage through Medicaid, those benefits end 60 days after delivery, leaving them without health insurance during a still precarious postpartum period.
“That 60-day cutoff is based on a false belief that pregnancy-related complications end then,” said Dr. Charlene Collier, an OB-GYN at the University of Mississippi Medical Center in Jackson, Mississippi, and chair of the state’s Mortality Review Committee, which tracks maternal deaths in the state. “Now we know those complications extend through the end of the first year.”
The easier bureaucratic pathway in this year’s American Rescue Plan won’t be available to states until next year. For the moment, however, no matter where they live, new mothers on Medicaid don’t have to worry about losing benefits after 60 days. That’s because the COVID-19 relief bill that former President Donald Trump signed last year prohibited the states from dropping anyone from Medicaid during the public health emergency.
Although new mothers with low incomes are already covered beyond 60 days in states that expanded Medicaid, states could increase the number of women who would be covered. That’s what Illinois has done.
Previously in Illinois, only women whose income was less than 138% of the federal poverty line qualified for the extended time on Medicaid. The state’s waiver now ensures new mothers up to 213% of the poverty line can continue on Medicaid after 60 days as well.
“We determined that over two-thirds of pregnancy-related deaths were potentially preventable, and that one-third of pregnancy-related deaths occurred more than 60 days postpartum,” said Dr. Robin Jones, an OB-GYN who chairs the state’s Maternal Mortality Review Committee, which had become alarmed after digging into the data and asked Illinois’ lawmakers to approve the waiver application.
Most states and some cities now have appointed maternal mortality review committees comprising medical experts who delve into the cause of each maternal death with an eye toward identifying medical and procedural improvements.
Some states that didn’t expand Medicaid benefits under the Affordable Care Act do provide Medicaid coverage for parents, but the income thresholds are usually extremely low, meaning only the poorest residents qualify.
For example, Texas parents only qualify for Medicaid if their incomes are 17% of the poverty line or less. For a family of three, that would mean an annual income of up to $3,733.
The movement to extend Medicaid’s postpartum benefits gained traction after the CDC published alarming findings about maternal deaths in 2019. The report revealed that 11.7% of pregnancy-reported deaths occurred from the 43rd day of pregnancy to one year after delivery. That figure likely represents an undercount, maternal health experts say, because it doesn’t include deaths related to overdoses and suicides, which might be partly driven by the mental stresses associated with maternity.
The CDC data also underscores the gaping disparity in maternal mortality between White and Black women. The number of pregnancy-related deaths per 100,000 live births for White women is 13; for Black women, it’s more than three times higher, at nearly 43.
The leading causes of deaths immediately after the end of pregnancy also were different than those occurring months later, the CDC analysis revealed. For women who died between the seventh and 42nd days after pregnancy, strokes and infection were among the leading causes of death. Women who died later were more likely to succumb to cardiomyopathy, a disease of the heart muscle that can lead to heart failure. Other prevalent causes at that stage were embolisms and other cardiovascular conditions.
Many OB-GYNs also say postpartum depression often doesn’t emerge until weeks after delivery.
Yet many women who receive health benefits through Medicaid during pregnancy lack coverage both before pregnancy and for most of the first year after delivery.
“What I see constantly in the communities I care for is a normal process,” said Ebony Marcelle, director of midwifery at Community of Hope, a community health center in Washington, D.C. “You get the 60 days, and you’re dropped.”
Uncovered Before and After
A new report in the journal Health Affairs in April found that more than one-third of women who were covered by Medicaid during their pregnancies were without coverage either before conception or within two to six months after pregnancy.
That accounts for a lot of women. More than four out of every 10 births in the United States are paid for by Medicaid, and the rate is even higher among women of color and residents of rural areas, according to Medicaid and CHIP Payment and Access Commission, a nonpartisan legislative branch agency that serves Congress.
“We’re basically saying we only value your health when you’re pregnant,” said Collier.
Untreated chronic conditions such as diabetes and hypertension can lead to more complications during pregnancy and contribute to preterm births and low birth weights, said Dr. Elizabeth Howell, chair of the obstetrics and gynecology department at the University of Pennsylvania Perelman School of Medicine. Those same conditions remain dangerous for women after delivery as well, she said, beyond the time when Medicaid coverage runs out.
“These are women with significant issues—diabetes, high blood pressure—that put them at significant risk,” Howell said. “We end up seeing late deaths of women who were lost to care instead of connected to the care” that might have saved them.