Restrictions on abortion likely will result in more unwanted pregnancies being carried to term. Experts predict that will worsen the nation’s already high rate of maternal deaths — unless states spend a lot more on health care and social and economic supports for women, children and families.
Many conservative state lawmakers continue to oppose such spending, but one federal-state health care program for pregnant women is gaining momentum.
Indiana and West Virginia, two states that recently banned nearly all abortions, received federal approval this month to offer women Medicaid-funded health care during their pregnancy and for 12 months after they give birth.
They join 23 other states and the District of Columbia that already have extended postpartum Medicaid coverage from two months to a full year after childbirth. Eight additional states — Alabama, Arizona, Colorado, Delaware, Georgia, New York, Rhode Island and Vermont — have applications pending.
Among the 26 states that have or are expected to ban abortion, 14 states have not yet applied for the full one-year postpartum extension: Arkansas, Idaho, Iowa, Mississippi, Missouri, Montana, Nebraska, North Dakota, Oklahoma, South Dakota, Texas, Utah, Wisconsin and Wyoming.
Wisconsin has proposed a limited Medicaid extension of 90 days after birth, and Texas has proposed a six-month extension.
Last week, Oklahoma Republican Gov. Kevin Stitt announced the state would make it easier for more patients to qualify for pregnancy-related Medicaid coverage by raising the income threshold from $18,754 for an individual to $27,859, and he said Oklahoma would consider applying for the extended postpartum Medicaid option.
“States are taking this option at record speed and with bipartisan support,” said Maggie Clark, senior state policy analyst at Georgetown University’s Center for Children and Families. “Now, they need to make sure they’re doing more than just turning on coverage. They need to let everyone know about it, prepare health care providers, set quality measures and make sure people can get to their appointments.”
The United States has the highest maternal mortality rate among developed countries — more than triple the rate in France, which has the second-highest rate. Maternal mortality rates include deaths during pregnancy, childbirth and the first year after delivery.
According to a 2022 analysis by the Commonwealth Fund, a nonprofit group that promotes health equity, the United States recorded 23.8 maternal deaths per every 100,000 births, with Black women dying at more than twice that rate — 55.3 per 100,000.
Pregnancy-related chronic illnesses, such as diabetes and high blood pressure, and complications during childbirth are major drivers of the high U.S. mortality rate, according to the U.S. Centers for Disease Control and Prevention. Suicide and drug overdoses also contribute.
Four out of five of those deaths, the CDC says, could be prevented. But reproductive health care providers and women’s health advocates worry that abortion bans will cause the United States to fall further behind.
A December 2021 study from the University of Colorado found that a nationwide abortion ban could increase pregnancy-related deaths by as much as 21% for the general population and as much as 33% for Black women.
“If you have a system that has already demonstrated itself not to be well suited to support pregnant people, particularly pregnant Black and brown people, then adding more people to that system is inevitably going to cause harm,” said Dorianne Mason, director of health equity at the National Women’s Law Center, which supports abortion rights.
As more states take up the option to extend Medicaid for the first critical year after childbirth, Mason said, it could improve maternal health to some degree. “But it is woefully inadequate. It’s like putting a Band-Aid on a bullet wound.
“It would be myopic to consider it a solution,” she said. “It doesn’t account for all of the health risks someone has to take on by carrying an unwanted pregnancy, and it doesn’t account for the mental health toll of carrying an unwanted pregnancy, and it doesn’t take into account what that person’s life and her child’s life will look like.”
A 2020 study by the University of California, San Francisco found that women who are denied abortions are at greater risk of death and poor physical health for years after childbirth.
In approving the new coverage, the U.S. Department of Health and Human Services estimated 12,000 Indiana residents and 3,000 West Virginia residents will receive the full-year postpartum coverage. Medicaid is a joint state-federal program.
Nationwide, the agency estimated 333,000 people are now covered by the Medicaid extension, and if all states applied for the option, as many as 720,000 people would be covered.
Medicaid, which pays for more than 40% of all births, ends two months after childbirth, when many women experience severe physical and mental health challenges. Women can reapply for Medicaid as a parent, but often do not qualify because the income thresholds tend to be stiffer for parents than for pregnant women.
In the past, states that wanted to extend Medicaid coverage beyond childbirth had to file extensive paperwork with the federal government through a process that could take a year or more. Under the American Rescue Plan Act of 2021, the Biden administration gave states a five-year window to apply for the program using a streamlined approval process.
Patrick Brown, a fellow at the conservative Ethics and Public Policy Center, called the postpartum Medicaid extension program “low-hanging fruit,” noting that the federal government pays for most of it under federal-state cost sharing formulas.
Brown said he cautions conservative state officials that to preserve the legal victory over abortion rights they sought for nearly 50 years, “they will have to be thinking more creatively beyond the same old, tired conservative economic pieties. They’ll have to respond to the needs of low-income women and women who are thinking about abortion.”
He agreed that extended Medicaid coverage alone is not enough to support an expected surge in demand for pregnancy-related care resulting from abortion bans in more than half of all states. But he said it’s a good place to start.
“A lot of states that are most likely to ban abortion tend to be ones with less fiscal capacity than, say California or New York,” he said. “They’re never going to be able to adopt the kind of sweeping social policies needed to support families such as paid leave and subsidized childcare. But extending postpartum Medicaid coverage is a small step those states can take.”