Some States Move Forward on Medicaid Extension to Improve Maternal Health

Several states are taking the first steps in what advocates say could be a big move in improving maternal health in the U.S., using a tiny provision in the American Rescue Plan. That provision would allow states to easily extend Medicaid coverage to low-income people up to one year after they’ve given birth.

“This is a step in the right direction towards addressing our nation’s growing maternal mortality crisis, which disproportionately impacts women of color and those living in underserved and more rural areas,” Illinois Sen. Tammy Duckworth said of the provision during a press conference Monday.

[READ: Illinois Gets OK for First-in-Nation Extension of Medicaid for Postpartum Mothers]

In the U.S., more than 40% of births are covered under Medicaid. According to the Kaiser Family Foundation, Medicaid covers roughly two-thirds of births among Black, American Indian/Alaska Native, and Native Hawaiian and other Pacific Islander women. However, low-income people who become eligible for the health insurance program are covered for just 60 days after giving birth. Losing coverage after that time, advocates say, can have fatal outcomes.

According to the Centers for Disease Control and Prevention, one-third of pregnancy-related deaths occur in the year after giving birth. Suzanne Wikle, project director for advancing strategies for aligning programs at the Center for Law and Social Policy, writes in a blog post that while Medicaid alone might not eliminate disparities in maternal health, “Medicaid has a role to play here — a significant role that can quickly leverage existing systems to provide needed health care in the postpartum period,” particularly for mothers of color.

The provision in the relief bill would allow states to extend Medicaid coverage to those who became eligible during pregnancy for up to a year after giving birth. It’s different from programs launched last year in two states, Texas and California, that allowed some low-income women to remain on Medicaid benefits up to one year after giving birth, but only under certain conditions.

For example, California’s program was for people who had been diagnosed with a maternal mental health disorder, such as postpartum depression. Both programs used state funds, not federal funding. The extension outlined in the American Rescue Plan would provide full benefits to all eligible people. The extension would also be permanent, but wouldn’t go into effect until next year.

It comes as the U.S. maternal death rate continues to climb, rising by 15% in 2019 just ahead of the pandemic. Meanwhile, momentum has built in recent years on Capitol Hill and in statehouses to improve maternal health. With a blue Congress and White House, maternal health advocates say they’re optimistic about what 2021 may bring.

Already, several states have signaled interest in the option. West Virginia’s state Legislature on April 10 passed legislation to extend Medicaid coverage to low-income women up to one year after giving birth. A spokesperson for Republican Gov. Jim Justice says if the bill is signed into law, the state’s health department will opt into using the state plan option indicated in the American Rescue Plan.

Julie Warden, chief operating officer of reproductive health advocacy organization West Virginia Free, says the bill saw significant bipartisan support.

“Our population has a lot of lower-income folks, and lower-income pregnant women need comprehensive health coverage, so they can get the health services they need to be healthy during pregnancy,” Warden says. “And so they can stay healthy as they take on the responsibility of becoming a parent.” She says the bill will not only save the state money in the long run but will lead to better birth outcomes.

“We’ll have fewer children at risk of out-of-home placement. And these mothers are going to be able to receive quality health care, to make sure she can take care of not only herself but her new baby,” she says.

Washington is taking a second stab at extending coverage after Democratic Gov. Jay Inslee vetoed a bill last April that would have extended Medicaid eligibility for those earning up to 193% of the federal poverty line to one year after giving birth. At the time, he cited the coronavirus pandemic’s strain on the budget. The latest bill, which was delivered to the governor’s desk on Monday, is unchanged and a spokesperson for the governor’s office says Inslee is supportive and will likely sign it.

[MORE: Medicaid Work Requirements in Limbo as Arkansas Hopes to Again Overhaul its Program]

Meanwhile, in Maryland, a bill introduced in March would extend coverage to postpartum people who are at or below 250% of the federal poverty line; but the program would use state funds, like California and Texas’ programs, and it isn’t yet clear if the state will move to adopt a state plan amendment.

Texas House legislators on Wednesday approved a bill to extend postpartum Medicaid coverage up to one year for low-income women who become eligible for Medicaid during pregnancy. This bill would go beyond the more limited and state-funded program the state implemented last year. Per bill text, the state can seek a waiver or other authorization, such as a state plan amendment, from federal authorities if it deems doing so necessary, even if that might delay the proposed September implementation.

Extending Medicaid postpartum has also garnered interest in states that have held out on fully expanding Medicaid coverage despite the American Rescue Plan incentivizing them to do so. In Florida, Republican House Speaker Chris Sprowls unveiled a bipartisan plan aimed at reducing maternal mortality rates, with a $240 million provision that would extend Medicaid postpartum coverage up to one year after giving birth. It’s not yet clear if the state will seek a state plan amendment if the bill passes.

The office of Florida Gov. Ron DeSantis told U.S. News that the governor is watching the bill as it unfolds and if a final version is passed “the Governor will make a determination (to seek a state plan amendment) that he feels is in the best interest of Floridians.”

In North Carolina, another non-expansion state, a bill was introduced in early April to direct the health department to use a state plan amendment to extend Medicaid up to one year postpartum to women at or below 196% of the federal poverty line. On a podcast with North Carolina’s public radio state, Democratic Gov. Roy Cooper again reiterated his support for a full expansion and hinted that the Republican Senate president may be willing to negotiate with him on it.

But the American Rescue Plan isn’t the only avenue to extending postpartum Medicaid. States can also submit waivers to the federal government, a different process that requires approval from the Centers for Medicare and Medicaid and allows for temporary coverage. On Monday, Illinois became the first state in the nation to have an approved waiver to extend postpartum Medicaid coverage.

The approval means low-income women in Illinois with incomes up to 208% of the federal poverty line can stay on Medicaid up to one year after they give birth, with full coverage. Unlike the American Rescue Plan which set the start date for extensions obtained through a state plan amendment in April 2022, Illinois’ coverage can begin immediately. However, while state plan amendments are permanent, Illinois’ coverage will end on Dec. 31, 2025, unless extended or made permanent.

Other states, including Indiana, Missouri, New Jersey and Virginia also have pending waivers. Georgia also has a pending waiver, although its waiver would only extend coverage for six months as opposed to one year. Medicaid and maternal health advocates have applauded the Illinois’ waiver approval and urged the Biden administration to approve the other pending waivers.

In a March letter to the CMS, the American College of Obstetricians and Gynecologists urged the federal government to unveil guidance on how states can take advantage of the new state plan option to extend coverage outlined in the American Rescue Plan.

On Monday, Health and Human Services Secretary Xavier Becerra praised Illinois’ waiver and called it a model to other states, while encouraging states to take advantage of the American Rescue Plan’s provision.

“That’s a big deal,” Becerra said, of the waiver approval. “We hope that other states will follow Illinois’ lead to expand coverage, and we encourage other states to take advantage of this new pathway when it’s available,” he said.

More from U.S. News

Illinois Gets OK for First-in-Nation Extension of Medicaid for Postpartum Mothers

Medicaid Work Requirements in Limbo as Arkansas Hopes to Again Overhaul its Program

COVID-19 Vaccine Eligibility by State

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