To help tackle US maternal health crisis, more states extend Medicaid postpartum coverage

By Jacqueline Howard, CNN

(CNN) — Texas has joined a growing number of states extending the period in which new moms can qualify for Medicaid insurance after giving birth, offering coverage beyond the required 60 days postpartum to 12 months.

On Friday, Texas Gov. Greg Abbott signed into law House Bill 12, which extends the duration of Medicaid coverage provided postpartum to a full year in that state, according to the office of Republican state Sen. Lois Kolkhorst, sponsor of the bill.

The rate of severe maternal morbidity – or pregnancy and childbirth complications – has increased in Texas.

“The Texas Legislature has made a significant commitment to the life of both mothers and their children. House Bill 12 is an important step in this continuum of care for mothers as they care for their children; they can be assured they will have proper care post-partum,” Kolkhorst said in an email Thursday. “In a post-Dobbs era, the Texas Senate and House have directed significant resources to the health of women, mothers, and children with appropriations nearing $1 billion. HB 12 is one bill in a package of bills aimed to improve health and outcomes for women and their children.”

Abortion is banned in Texas – one of the most restrictive abortion laws in the developed world – which led lawmakers to debate the language used in HB 12, ultimately including an amendment clarifying that the extended Medicaid health coverage is “for mothers whose pregnancies end in the delivery of the child or end in natural loss of the child. This does not include pregnancies that end through elective abortion.”

More than half of states extend coverage

So far, an additional 35 states and the District of Columbia have extended their Medicaid postpartum coverage to a full year after giving birth, according to data from the nonprofit KFF, formerly known as the Kaiser Family Foundation.

New York also extended coverage recently.

“New York’s efforts reflect the groundswell of support for setting families on firm footing by extending postpartum coverage to a full year after pregnancy,” Chiquita Brooks-LaSure, the administrator of the Centers for Medicare and Medicaid Services, said in a news release Tuesday. “The Biden-Harris Administration has prioritized maternal health and will continue to do so until all 50 states and every U.S. territory can offer pregnant women and their families the lifeline that comes with connections to health coverage.”

Maternal health advocates hope that the extensions will play small yet crucial roles in tackling the nation’s maternal mortality crisis. About 1 in 3 pregnancy-related deaths occurs about a week to one year after delivery, according to the US Centers for Disease Control and Prevention.

“It’s really important for people to have coverage before, during and after pregnancy, outside of pregnancy, and we know that having coverage enhances your access to care,” said Usha Ranji, associate director for women’s health policy at KFF, whose team has been tracking how many states have extended Medicaid postpartum coverage.

“Medicaid actually pays for more than 4 in 10 births nationally. So when it comes to looking at issues of maternal health, Medicaid is a big player, and that’s really the impetus behind tracking these policies,” she said. “For decades now, Medicaid coverage for pregnant people has ended in 60 days postpartum. That has been federal policy for many years. And so when the American Rescue Plan passed, it included this option for states to extend to a year.”

Last year, in an effort to reduce maternal mortality and morbidity in the United States, the Biden-Harris administration encouraged states to extend Medicaid’s postpartum insurance coverage requirements from two months after birth to a full 12 months.

In that announcement, the administration called for ensuring that women giving birth are taken seriously when they raise concerns, diversifying the workforce of perinatal health-care staff, strengthening economic and social supports for patients, advancing data collection and research, and increasing access to maternal health services that include behavioral health – all part of its maternal health blueprint plan.

As of now, according to the KFF tracker, only three states either have not extended Medicaid postpartum coverage, have not proposed plans to do so or don’t have pending legislation that passed at least one chamber: Arkansas, Idaho and Iowa.

“Some states have just not taken it up because they may not want to have any expansion of Medicaid benefits. But that being said, it’s really important to keep in mind, most states have now done this and have now extended postpartum coverage for 12 months, at least,” Ranji said. “And if you look at the map, it’s not just blue states. There are red states there too, some in the South.”

Medicaid postpartum coverage extension is different from full Medicaid expansion in a state.

When it comes to coverage before pregnancy, Ranji said, there appear to be higher rates of coverage before pregnancy in states that have adopted full Medicaid expansion. As of late May, 41 states and DC have adopted full Medicaid expansion and 10 states have not, according to KFF.

“Coverage and access to care before pregnancy is also important for a health pregnancy and postpartum period,” Ranji said.

As for only extending Medicaid postpartum coverage, the process for a state to do so can take some time, needing action from state legislators and a financial commitment from the state.

“The determination by a state to extend postpartum coverage may require authorization from the state legislature and likely requires the legislature to appropriate additional state funding to finance the extension of coverage for this population,” Hemi Tewarson, executive director at the National Academy for State Health Policy, which also tracks state efforts to extend Medicaid postpartum coverage, said in an email.

“Going from 60 days postpartum of coverage to 12 months has a cost that will be different for each state as it depends on each state’s federal medical assistance percentage (FMAP) and how many individuals will be eligible for Medicaid due to pregnancy and their income,” she wrote. “There may also be some state policymakers who are hesitant to expand federal coverage programs.”

Maternal deaths on the rise

The rate of women across the United States dying due to pregnancy or childbirth each year has been getting worse.

A report from the National Center for Health Statistics, released in March, found that the US maternal death rate for 2021 – the year for which the most recent data is available – was 32.9 deaths per 100,000 live births, compared with rates of 20.1 in 2019 and 23.8 in 2020.

The total number of women who died of maternal causes in the United was 1,205 in 2021, up from previous years: 658 in 2018, 754 in 2019 and 861 in 2020.

“States are also using other Medicaid policy levers to address the maternal mortality crisis such as providing reimbursement for doula and midwifery services,” Tewarson said.

“Medicaid coverage of community-based providers such as doulas and midwives can improve health outcomes for pregnant and postpartum people, especially those who are low-income and people of color,” she said. “Research shows doula and midwifery care is associated with healthy birth outcomes including lower cesarean rates, fewer obstetric interventions, fewer complications, decreased likelihood of preterm birth, and more.”

Tewarson added that 10 states, including Washington DC, implemented a doula Medicaid benefit and all states currently reimburse services performed by certified nurse-midwives.

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