Can more time on Medicaid lower maternal deaths?

Dan Gorenstein, Andrea Perdomo – Tradeoffs

For a country that touts family values, the United States has long had a problem taking care of people who are pregnant.

Every year, some 60,000 women experience health complications related to their pregnancy. On average, 700 die.

Research shows more than half of those deaths are preventable. And people of color, particularly Black women, are three times more likely to die of those health complications than White women.

Last year, the Biden administration moved to address those disparities and improve maternal health. The plan: Keep pregnant people covered by Medicaid – the health insurance program for low-income people – longer after giving birth.

Research shows more than half of maternity-related deaths in the U.S. happen within a year after giving birth. States have begun tackling maternal mortality by creating mortality review panels and various committees. But rates keep climbing. In 2020, 861 women died — 107 more than the year before.

To understand why the White House pushed for this policy and how it will work, it’s helpful to look to Louisiana, one of the first states to adopt the new program.

In 2018, Louisiana's maternal mortality rate exceeded the national average.

“As a state, we have a saying that we're on the bottom of the good list and the top of the bad way too often,” said Stacey Roussel, the deputy director of the nonpartisan Louisiana Budget Project.

Roussel’s organization backs policies to help low-income and working class people. In Louisiana, to talk about maternal mortality is to talk about deep poverty.

Louisiana has the second-highest poverty rate in the country.

Maternal health advocate Frankie Robertson with the Amandla Group says there are several ways that impacts people's access to pregnancy care: “Not having adequate child care. Not being able to leave work and sacrifice pay to sit for hours at a prenatal appointment or a postpartum appointment.”

Both Robertson and Roussel have lobbied Louisiana lawmakers for years to adopt stronger protections for pregnant people. The passage of the federal American Rescue Plan last year presented Louisiana with a unique opportunity.

The law included a provision that allows states to amend their Medicaid programs and help cover the cost of expanding postpartum coverage from two months to a full year.

Medicaid covers more than 4 in 10 births nationwide and 6 in 10 births in Louisiana.

After the state expanded Medicaid under the Affordable Care Act in 2016, nearly all single adults with annual incomes up to $18,000 — including pregnant women —- now have coverage.

But pregnant people still face gaps in their insurance.

Some women drop off the rolls for paperwork mistakes, Roussel said. Others move or miss an eligibility check in. In a state fueled by tourism, it’s also common for people to see a seasonal spike in income, followed by a drop.

“There's a lot of churn, so people lose their coverage and then come back," she said. “When you have that kind of disruption in care during that first 12 months after the birth of a child, that can be really disruptive.”

A 2021 federal report found that some 14,000 pregnant people in Louisiana would benefit from expanding postpartum Medicaid to 12 months.

If Louisiana embraced the plan, Washington would pay $63 million to cover the federal government’s share of the five-year program. The move would cost Louisiana $18.5 million, less than $5 million a year.

Louisiana lawmakers ultimately balked.

Instead, the Louisiana Department of Health agreed to pick up the tab.

Expanding Medicaid postpartum is catching on. Nearly 40 states have adopted or have pending legislation to extend pregnancy-related Medicaid, including nine non-Medicaid expansion states like Georgia, South Carolina and Tennessee.

The evidence that health care coverage reduces maternal mortality rates is limited to one study from the Columbia University School of Social Work that found states that had expanded Medicaid under the Affordable Care Act had lower rates of mortality compared to states that did not expand their programs.

“They found that Medicaid expansion was significantly statistically associated with lower maternal mortality rates,” said Usha Ranji, associate director for women’s health policy at the Kaiser Family Foundation.

More research is needed, but “it makes sense that broader access to health care across someone's lifespan would help address and identify earlier problems like mental health [and] chronic conditions like heart disease,” Ranji said.

Ranji and other experts say reducing preventable deaths and other postpartum health problems requires more than increased health coverage.

“I'm talking about issues like income, poverty, housing that all play a role in somebody's health,” Ranji said.

She also pointed to the need to address structural racism and bias. Pregnancy mortality figures, said Ranji, suggest this corner of medicine marks one of the starkest areas of racial and ethnic inequality.

“If you look at the data across income, across educational levels, one constant is that Black women are affected more,” she said. “For example, in California, there's actually been a decline in overall mortality rates, but there is still a wide gap when it comes to race and ethnicity.”

Ranji believes part of the problem is doctors and nurses not giving credence to the insights from their patients of color.

“I've listened to a lot of stories,” Ranji said, “and a common theme among many of them is people saying that they or their loved one knew something wasn't right, and that they weren't being listened to.”

There is a chance all states will be required to expand postpartum coverage for a full year. That provision is tucked into the Build Back Better plan that passed the U.S. House, but is stalled in the Senate.

Dan Gorenstein is the executive editor of the health policy podcast Tradeoffs, and Andrea Perdomo is a reporter/producer for the show, which ran a version of this story on May 26. 

Side Effects Public Media is a public health news initiative based at WFYI.

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