Postpartum coverage and benefits are essential, but only the start of the necessary Medicaid work to address the maternal health crisis – Center for Children and Families

Federal and state leaders have prioritized maternal health in Medicaid in recent years, with welcome (if belated) attention. If Say Ahhhh! Readers know that the new state option to extend postpartum coverage to 12 months for all pregnant women in Medicaid has been adopted or is underway in all but two states since the federal match became available in April 2022.

Idaho and Iowa are the last of the remaining states to expand postpartum coverage — which is generally good news. But unfortunately, Iowa’s extension comes with a dramatic trade-off: a rollback of Medicaid eligibility for pregnant women from 375% to 215% of the federal poverty level (FPL). Although current pregnant beneficiaries will receive postpartum coverage, affordable coverage will not be available in coming years for uninsured Iowans who become pregnant with a monthly income of $4,700 or more for a family of three – an estimated 1,300 pregnant women or more in a given month. And to make matters worse, 400 of their babies (or ‘so-called newborns’) will also miss out on coverage in their first year. So pregnant people who want to work a few more shifts or hours to save more money before a new baby is born can’t sign up for affordable coverage and get the prenatal care they need. This could result in more Iowans unnecessarily incurring significant medical debt to access necessary prenatal care.

But wait: Can’t pregnant women above 215% FPL in Iowa get subsidies for affordable market coverage? It turns out: NO! Iowa leaders decided against running a state-based ACA marketplace and instead joined the federal marketplace. Pregnancy is not a qualifying condition to enroll in the federal marketplace outside of the open enrollment period, usually November 1 to December 31 of each year. (Medicaid and CHIP allow enrollment at any time.) This means that any working, uninsured person making more than $4,700 a month can hope to find out they are pregnant late in the fall during open enrollment . Otherwise, they will have to wait until the child is born before getting coverage on the market. Iowa lawmakers could have created a parallel state CHIP option for pregnant women at higher income levels, losing Medicaid coverage to fill the gap, but chose not to do so.

To be clear, a policy designed to give more pregnant women access to postpartum care will only come about because Iowa lawmakers eliminated access to care. each affordable coverage for pregnant women and newborns in working families. Not only will fewer pregnant women benefit from a full year of postpartum coverage, but fewer women will qualify for Medicaid coverage in the first place, missing out on crucial prenatal care. All signs point to a quick signature from Iowa Governor Kim Reynolds.

But even without benefit cuts that undermine the benefits of comprehensive postpartum coverage, we know that postpartum extension alone will not solve the maternal health crisis. Coverage itself is a necessary but insufficient step to address the dire maternal health crisis that disproportionately impacts Black and brown women. And while it’s encouraging to see more states taking steps to cover new services for pregnant and postpartum women in Medicaid, such as doula care, no intervention or service can undo years of health care system inaction, including an unwillingness to really listen to the needs of pregnant women. women and their families. As we noted in our recent report, Medicaid leaders must assess the full continuum of health care for pregnant women, from promotion to treatment, and use policy and system changes to address gaps. This could mean improved primary care, access to community health workers or doulas, mental health care, nutritional support, connections to health-related social needs, and others. And even with the best policies, how can states best ensure that pregnant women get the care they need when they need it as Medicaid agencies make changes to cover more types of providers or services?

This leads us to a second state—California—where state leaders have dropped a comprehensive benefit for pregnant women, despite strong early evidence of its value in reducing the number of low-birthweight infants. There may be other positive results to share, but they stopped paying attention long ago. A February state auditor report summarized:

The Legislature established the Comprehensive Perinatal Services Program in 1984, which provides enhanced medical services to pregnant and postpartum Medi-Cal members. These services include health education, nutrition education, and mental health assessments and interventions. The aim of the program is to reduce morbidity and mortality among mothers and children. State law places authority for the perinatal program in the Department of Health (Public Health). However, another state department – ​​the California Department of Health Care Services (Health Care Services) – is responsible for Medi-Cal and contracts with managed care plans, requiring them to provide perinatal services similar to the perinatal program’s care. Public Health administers the perinatal program as offered through benefit plans. Neither department provides sufficient oversight to ensure that Medi-Cal members receive program services or that providers and Medi-Cal members are informed about the program.

Despite two government agencies had the responsibility to ensure that the comprehensive perinatal services program worked effectively for pregnant women, both in terms of fee-for-service (public health) and managed care arrangements (Medi-Cal’s agency), lack of agency oversight, and the managed care organization plan (MCO) The responsibility has led to fewer pregnant women being aware of the services or using them. This may reflect the troubling decline in public investment in state agency capacity, but nonetheless, state lawmakers have – directly or indirectly – started with a comprehensive benefit for pregnant women and then failed to fully appreciate its value and the potential for improvements after the first years. The lack of oversight of care is not surprising, given the serious lack of publicly available information reported in my colleagues’ recent scan of twelve states’ Medicaid health plan performance on maternal health. But it is still seriously concerning.

Ensuring that Medicaid coverage reaches its full potential and meets the needs of pregnant women, children, and their families requires an intentional, sustained effort to engage with the families themselves. It also requires monitoring that most states are challenged to meet increasingly competitive demands and declining resources and personnel. Promising solutions to the maternal health crisis require leadership and a commitment to continuous quality improvement. Leaders at all levels should keep in mind that Medicaid is a central payer of births and continue to focus on the quiet, necessary work needed to ensure it is fully utilized to ensure high-quality health care that improves the health of can help mothers improve in a meaningful way.