Expanding Medicaid Coverage for Birthing People to One Year Postpartum

Abstract
This policy statement is a new late-breaker APHA policy that advocates for the extension of postpartum Medicaid coverage to one year postpartum. Rates of pregnancy-related mortality (death during pregnancy or within one year of the end of pregnancy) and severe maternal morbidity are high and rising, with significant disparities and preventable excess deaths occurring among Black and indigenous women. Research indicates that more than half of pregnancy-related deaths are preventable and that continuous postpartum coverage is an important strategy to reduce maternal mortality and morbidity. Variations in the risk of pregnancy-rated death by race/ethnicity are associated with multiple factors, including structural racism and its impact on access to high-quality and unbiased health care. In 2019, Medicaid financed an estimated 42% of U.S. births overall and 65% of births to African Americans, 59% to Latinas, and 29% to Whites. Federal law currently limits postpartum Medicaid coverage to 60 days, leading to high proportions of birthing people becoming uninsured. The American Rescue Plan Act gives states the option to extend Medicaid coverage from 60 days to 12 months postpartum (effective April 1, 2022). Some states are using waivers to extend coverage. This APHA policy statement calls for Congress to make Medicaid 12-month postpartum coverage mandatory nationwide (or alternatively for states to use the option to extend postpartum coverage) and health care leaders to maximize the impact of coverage and provide adequate reimbursement for a range of services and providers (e.g., doulas, midwives, community health workers, physicians, nurses, and dentists).

Relationship to Existing APHA Policy Statements

• APHA Policy Statement 200318: Safe Motherhood in the United States: Reducing Maternal Mortality and Morbidity
• APHA Policy Statement 20004: Supporting Access to Midwifery Services in the United States
• APHA Policy Statement 201113: Call to Action to Reduce Global Maternal Neonatal and Child Morbidity and Mortality
• APHA Policy Statement 201114: Reducing US Maternal Mortality as a Human Right
• APHA Policy Statement 200714: A Call to Action on Breastfeeding: A Fundamental Public Health Issue
• APHA Policy Statement 20153: Universal Access to Contraception
• APHA Policy Statement 20192: A Global Call to Action to Improve Health Through Investment in Maternal Mental Health
• APHA Policy Statement 20203: Improving Access to Dental Care for Pregnant Women through Education, Integration of Health Services, Insurance Coverage, an Appropriate Dental Workforce, and Research (This policy statement is needed to specifically address the core components of Medicaid expansion not addressed in the above policies to improve access to and quality of postpartum care.)

Problem Statement
Research and data indicate that more than half of pregnancy-related mortality is preventable overall and during the postpartum period. Offering birthing people continuous insurance coverage for one year postpartum is a key component of the set of actions needed to make substantial progress to reduce maternal morbidity and mortality with a focus on reducing disparities in outcomes by race and ethnicity. 

Maternal mortality and morbidity: Tragically, in the United States, pregnancy-related mortality (defined as death during pregnancy or within one year of the end of pregnancy from a pregnancy complication, a chain of events initiated by pregnancy, or the aggravation of an unrelated condition by the physiological effects of pregnancy) is significantly higher than in other high-income developed countries. Furthermore, the U.S. rate of pregnancy-related mortality was 17.4 per 100,000 live births in 2017, an increase from 7.3 per 100,000 in 1987.[1] Significant health disparities exist by race/ethnicity, with 41.7 deaths per 100,000 live births among birthing people who identify as Black or African American, 28.3 among those who identify as American Indian or Alaska Native, and less than 14 per 100,000 among those who identify as non-Hispanic White, Asian/Pacific Islander, or Hispanic. The United States failed to meet Healthy People 2010 goals as well as the more recent Healthy People 2020 goals for reducing maternal mortality and morbidity.[2] 

Causes of pregnancy-related death vary according to health status, health care access, race and ethnicity, and timing of death. Cardiovascular conditions (e.g., cardiomyopathy, hemorrhage, embolism) and hypertensive conditions (e.g., preeclampsia and eclampsia) are the most common causes of pregnancy-related deaths and contribute to severe maternal morbidity (SMM).[1] Variability in the risk of pregnancy-rated death by race and ethnicity is associated with multiple factors including, but not limited to, structural racism and its impact on access to care, health care quality, prevalence of and care for chronic diseases, and implicit racial bias[3–5] in the health care system.[6]

Also important, SMM (defined as unexpected outcomes of labor and delivery that result in significant short- and long-term consequences to health[7]) has been increasing steadily in recent years. According to the Centers for Disease Control and Prevention,[7] SMM affected more than 50,000 people giving birth in the United States in 2014, with one in six SMM-causing events occurring among Medicaid-insured women.

Significant attention has been directed toward provider-, hospital-, and systems-based strategies to address this crisis. These efforts are necessary but insufficient. Solutions focused on the time and setting of births address only a fraction of the problem. Notably, one third of pregnancy-related deaths occur after the first week through one year postdelivery, a time when women have the least interaction with the health care system and arguably when they need health care interaction the most.[1] Community-based support and health care in the year following pregnancy are equally important.[8,9] Moreover, experts increasingly call for better financing and use of evidence-based approaches for group pregnancy care, enhanced prenatal care, freestanding birth centers, and a care team that includes doulas, midwives, and community health workers.[10]  

Role of Medicaid in financing maternity care and women’s health: Medicaid, along with the Children’s Health Insurance Program (CHIP), has a wide impact on women’s health across the life span, particularly their reproductive health. Medicaid covers 25 million U.S. adult women, and roughly two thirds are in their reproductive years (19–49 years of age). In 2018, 54% of Medicaid and CHIP enrollees were women.[11] Among women 15 to 44 years old, 42% identifying as non-Hispanic White, 28% as Latina, 21% as Black or African American, and 5% as Asian/Native Hawaiian or other Pacific Islander were enrolled in Medicaid or CHIP in 2018.[11] Reflecting long-standing policy decisions, Medicaid covers a disproportionate share of women in vulnerable populations, including 41% of women with incomes below 200% of the federal poverty level, 36% of those who are single parents, 39% of those with less than a high school education, and 35% of those living with disabilities.[11]

In 2019, Medicaid financed an estimated 42% of births in the United States overall and as many as 60% to 70% of births in various states.[12] According to self-reported birth certificate data, among those who gave birth in 2019, Medicaid provided coverage for 65% of women identifying as Black or African American, 59% of those identifying as Latina, and 29% of those identifying as non-Hispanic White.[13] These birth certificate data may underestimate actual coverage rates, with more than 60% of Black or African American, Latina, and indigenous babies having Medicaid coverage during their first year.[14]

Hundreds of thousands of women qualify for Medicaid coverage on the basis of their pregnancy; that is, they were not eligible prior to their pregnancy and have only pregnancy-related coverage.[12] For these women, federal law set a standard of coverage from pregnancy determination to 60 days after the end of the pregnancy, including live birth and fetal loss. This federal limit of postpartum coverage to 60 days leaves high proportions of women uninsured for the remainder of the first year after pregnancy. More than 20% of pregnant women become uninsured between two and six months postpartum.[11]

In addition to its role in financing maternity care, Medicaid is the single largest source of public funding for family planning services,[15] including contraceptive methods as well as screening for sexually transmitted infections, cancer, and HIV. Medicaid plays a key role in financing family planning services in Title X clinics, federally qualified health centers, and other settings. Moreover, Medicaid is a primary payer of mental health services and an important source of health coverage for people with breast or cervical cancer. 

States also have the option under the Affordable Care Act (ACA) to provide coverage under Medicaid for most people (of any gender) with incomes below 138% of the federal poverty level. As of July 2021, 38 states and the District of Columbia had adopted or implemented measures to expand Medicaid coverage under the ACA, whereas 12 states had opted out of expanding coverage.[16] This creates gaps in coverage for women of childbearing age, especially in southern states.  

The ACA Medicaid expansions have had a substantial impact on preconception, pregnancy, and postpartum coverage. For example, the expansions reduced insurance “churn” and shifts for pregnant and birthing people.[17] Prior to the expansions, one third of women experienced disruptions in insurance coverage.[18] In addition, about a quarter experienced insurance changes within nine months of pregnancy, and 28% experienced changes during the postpartum period.[18,19] In 2017, 35.6% of women reported having Medicaid coverage during their pregnancy (prenatal care), but this proportion decreased to 29.7% after delivery (postpartum care).[20] The Centers for Medicare & Medicaid Services found that, in 2019, only 61% of women across 39 reporting states received a postpartum care visit.[20]

Black, indigenous, and people of color (BIPOC) experience higher rates of disruptions in insurance than non-Hispanic White birthing people.[21] Hispanic and indigenous women in lower-income categories also have a higher probability than non-Hispanic White women of losing their insurance during the perinatal period.[21] In addition, pregnant and birthing people in states without Medicaid ACA expansions are twice as likely to be uninsured as those in states with ACA Medicaid expanded coverage (22.6% and 10.7%, respectively).[19] 

Changing policy to expand Medicaid postpartum coverage: On March 11, 2021, President Biden signed into law the American Rescue Plan Act (ARPA), which provides needed relief from the health, social, and economic effects of the COVID-19 pandemic. Included in the ARPA is a new pathway allowing states to extend Medicaid coverage for pregnant and birthing people from 60 days after birth to cover maternity care up to one year postpartum. Effective April 1, 2022, states can expand coverage by obtaining federal approval for a state plan amendment (SPA) to their Medicaid program.[20] This new federal law is not mandatory for states but is available as an option to states for five years. The SPA pathway will also be available to states that provide maternity coverage for pregnant women under CHIP.[22] As discussed below, the SPA is in addition to the opportunity for states to use Medicaid waivers to extend postpartum coverage, and this new expansion option offers advantages for birthing people and state agencies.

Evidence about loss of coverage postpartum: Among women who gave birth between 2011 and 2015, approximately 51.7% of pregnancy-related deaths occurred within the postpartum period (defined as one day postpartum to 365 days postpartum).[23] Approximately one in seven women enrolled in Medicaid developed severe pregnancy complications after they were discharged from labor and delivery.[24] Expanding coverage during the postpartum period has been associated with improvements in maternal health and health insurance access. Eliason found that expanding Medicaid under the ACA was associated with significant reductions in maternal mortality rates relative to states that did not expand coverage.[25] In addition, Daw and colleagues found that Medicaid expansion under the ACA led to a significant increase in the proportion of low-income women with continuous health insurance coverage throughout the perinatal period.[26] Several national organizations, including the American College of Obstetricians and Gynecologists and the American Medical Association, have endorsed the value of expanding Medicaid coverage throughout the postpartum period for preventing pregnancy-related mortality and morbidity.[22,27]

Extended Medicaid coverage can address health care system challenges and opportunities: Many pregnant and birthing people fall into cracks or chasms between maternity care and ongoing primary or specialty care in the postpartum year, even when medical and/or social complications of pregnancy signal the need for care. BIPOC are especially harmed by fragmented care and access disparities, coupled with the impacts of structural racism over the life course and bias and unequal treatment in health care.[28] 

During pregnancy, at the time of birth, and in the postpartum period, women may receive medical care from a wide array of providers, often resulting in a lack of continuity of care. Recent studies of high U.S. maternal mortality and morbidity rates point to the role of fragmented and discontinuous care in adverse outcomes.[29] For most U.S. pregnant people, prenatal care involves multiple providers.[30] In the birth setting, care may be managed by a hospitalist the woman has not previously met, and birthing people often leave a hospital within 48 hours after a birth.

This lack of continuity of care contributes to missed postpartum visits.[29,30] Postpartum visit rates for women in Medicaid average 50% to 60%, and studies suggest that only one third of women who received prenatal care attended their postpartum visit.[31] A recent study of postpartum utilization among birthing people who retained Medicaid coverage for 90 days showed that the frequency of postpartum visits, contraceptive service use, and routine preventive care was low.[31] Cost is another contributor to low rates of use of postpartum care. Loss of Medicaid maternity coverage at 60 days postpartum leaves many women without a source of financing to continue with their prenatal provider or another provider.  

Nearly 100 experts and innovators were engaged in a process from 2018 to 2021 that identified six key strategic areas for bridging the chasm between pregnancy and health care across the life course. These key areas were as follows: (1) progress toward eliminating institutional and interpersonal racism and bias; (2) infrastructure support for community-based organizations; (3) delivery of holistic, team-based care during pregnancy and the postpartum year and beyond, with integration of doulas and community health workers into the team; (4) extension of postpartum Medicaid coverage, supported by new quality and pay-for-performance metrics to link maternity care and primary care; (5) information systems change to preserve maternal narratives and data across providers; and (6) alignment of research with women’s lived experiences.[28,32]

In addition, lack of attention to and measurement of health care quality, along with quality improvement initiatives that do not focus on advancing equity, contributes to continued disparities in outcomes for birthing people of color and their babies. U.S. maternity care varies widely from region to region, state to state, and even hospital to hospital, demonstrating a lack of adherence to national standards of care. For example, a low-risk first-time pregnancy may be 15 times more likely to result in a cesarean section delivery in one hospital versus another, leading to increased risks of short- and long-term complications.[33] Variations in practice may be driven by hospital policy or provider attitudes and bias rather than quality of care standards or patient choice.[33,34] During the postpartum period, women experience many challenges, and what is often referred to as the fourth trimester can involve a number of health concerns for women and their babies.[35] Quality postpartum care to identify and address health risks, as well as social risks, is important in lowering rates of pregnancy-related mortality and SMM. Without quality postpartum visits, SMM cases can remain overlooked and untreated.[35]

Evidence-Based Interventions and Strategies
Despite the current high maternal mortality and morbidity rates in the United States and evidence supporting the benefits of adequate maternal health care for the well-being of women, birthing people, and their children, there is still a lack of standardized continuous perinatal care. The current evidence base can provide guidance for postpartum health care prevention and treatment strategies during the extended postpartum period. This policy statement advocates for a nationwide effort to expand and extend Medicaid services for one year postpartum through efficient use of federal and state policies.[22] In addition to making services equitable and more comprehensive for all populations through evidence-based strategies coupled with policy and programmatic changes,[22] expanding and extending Medicaid services will facilitate a number of health improvements for birthing people, as described below. 

Evidence-based preventive screening and interventions for women’s acute and chronic health conditions: There is a need for evidence-supported preventive screening services for average-risk women of all ages (including the peripartum period), including those identified by the United States Prevention Services Taskforce, Healthy Start, the Advisory Committee on Immunization Practices, and the Women’s Preventive Services Initiative.

Breastfeeding resources/lactation consultation: National and international organizations and experts recommend breastfeeding to provide optimal child and maternal health.[36] The American Academy of Pediatrics recommends exclusive breastfeeding for six months and continuation of breastfeeding to one year. The Office of Disease Prevention and Health Promotion reported that, in 2015, only 35.9% of infants in the United States were breastfeeding at one year, leading to the Healthy People 2030 objective to increase the proportion of infants breastfeeding at 12 months with a target of 54.1%.[36] Early breastfeeding cessation and interruptions increase maternal risk of ovarian and breast cancer, hypertension, cardiovascular disease, and diabetes.[37] Women with difficulty breastfeeding have a higher risk of postpartum depression, which leads to a decrease in breastfeeding duration.[37] Strategies to increase rates of sustained breastfeeding include insurance coverage for breast pumps[37]; community-based assistance, including peer support groups; and support from certified lactation professionals to assist with pain during breastfeeding, maternal medication education, and issues with low milk supply.[36,37] Expanded Medicaid coverage can increase access for U.S. birthing people to these evidence-based forms of breastfeeding support.[37]

Mental health screening and follow-up: Professional recommendations call for all women to be screened at least once during the perinatal period for postpartum depression, ideally during a comprehensive postpartum visit.[38] Since approximately 10% of women experience some form of postpartum depression (with 90% of episodes occurring within the first four months postpartum), screening during this time frame is imperative.[38] Treatment options can vary, are dependent on the severity of the depression, and include either psychosocial or pharmacological therapies.[30] While severe mental health issues (e.g., postpartum depression and suicide) are often observed as early as four weeks postpartum,[36] mental health issues may emerge at any time within the first year postpartum.[39] Recent evidence shows that women who lose insurance coverage may suffer from untreated depression, limited access to family planning services, and a lack of medical care for untreated diabetes or hypertension.[40] Expanding Medicaid coverage to 12 months postpartum would fill gaps in maternal mental health coverage and help reduce the incidence of mental health disorders and preventable pregnancy-associated deaths.[22]

Family planning: Women are at an increased risk of unintended pregnancy during the postpartum period.[41] In the United States, 45% of all pregnancies and 70% of pregnancies that occur in the first year postpartum are unintended.[41] Medicaid is the single largest source of public funding for family planning services. Since 1972, states have been required to provide coverage for family planning services for traditional Medicaid populations, and under the ACA states have the option of offering family planning services to people who would not otherwise be eligible for Medicaid. As of 2021, 26 states had received federal approval for expanded population coverage of family planning.[42] All state Medicaid programs must offer some family planning benefits, and most provide coverage for prescription contraceptives as well as health education, testing and treatment for sexually transmitted infections, cervical cancer screening, and screening for obesity, smoking, and mental health conditions.[43] Some states set limits and implement utilization controls such as quantity limits on injectable or oral contraceptives, whereas other states permit dispensing a full 12-month supply of oral contraceptives.[44] Expanding Medicaid coverage will help ensure critical access to family planning services among postpartum birthing people and the larger population at risk for unintended pregnancy. 

Home visiting: States have been using Medicaid financing to support home visiting services for decades. Over the past 30 years, a series of studies have documented the effectiveness of home visiting programs in improving outcomes among mothers, infants, and young children. While these studies generally do not show an impact on maternal or infant mortality, home visiting services are associated with increased use of prenatal and postpartum care, along with well-woman visits and mental health services, all of which are associated with improved health outcomes for birthing people and their families. The federal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program was established in 2010 to provide grants to states and is administered by the Health Resources and Services Administration.[45] MIECHV emphasizes use of home visiting programs that meet evidence-based criteria of the Department of Health and Human Services through Home Visiting Evidence of Effectiveness monitoring. In 2020, 21 models met the criteria, with eight of these models being in widespread use by states. More than 20 states currently use various types of SPAs, waivers, and managed care arrangements to finance home visiting,[46] and Medicaid expansion would allow more individuals the opportunity to benefit from home visiting services. Expanding Medicaid coverage would expand access to these evidence-based programs for birthing people and their families.

Oral health: Screening and counseling for oral health is an important part of perinatal care because lack of dental care is associated with adverse maternal and birth outcomes; however, only 20% of maternity providers include these services. Of particular concern are significant racial and ethnic disparities in oral health care for pregnant people.[47] Disparities also exist by payer status; 36% of women with Medicaid report having seen a dentist in the past year, as compared with 71% of women with private insurance.[47] Even among those whose coverage continues after the 60-day postpartum limit, Medicaid coverage of dental benefits may lapse because dental care is not considered pregnancy related.[47] With expansions, however, Medicaid can be an important tool for promoting access to and use of dental care during pregnancy and the postpartum period.

Workforce: Regardless of states’ Medicaid expansion status, having an adequate and appropriate workforce is essential to ensuring access to pregnancy-related health care. Given the role Medicaid plays in providing maternity health care services to communities of color, states expanding Medicaid coverage must ensure that adequate training and workplace personnel are in place to meet the needs of the perinatal and postpartum population for one year postpartum.[48] Medicaid expansion would continue to finance care delivered by physicians, nurses, midwives, freestanding birth centers, hospitals, and clinics. In addition, Medicaid can finance perinatal care delivered by doulas and other community health workers, lactation consultants, and nutritionists to address postpartum health care needs and work toward lowering rates of pregnancy-related death and morbidity.

Ensuring anti-racist, unbiased service delivery: Addressing racism, implicit bias, and inequities in health care is key to reducing the high U.S. rates of pregnancy-related mortality and morbidity. Centering postpartum care services around frameworks with a focus on women of color is essential to resolve persistent maternal health disparities. An approach that adopts theories and frameworks such as reproductive justice, critical race theory, public health critical race praxis, cycle of respectful care, and relationship-centered care has the potential to reduce the negative maternal health outcomes that result from racism and racial discrimination.[48,49] A 2019 through 2020 congressional session referenced pending bills to support coverage for doulas, broadening provider networks in rural areas and increasing training of providers on health equity and implicit bias. Incorporating unbiased, anti-racist training into maternity care in the United States may improve maternal mortality rates and maternal health outcomes among minority women and birthing people.[49] A large percentage of pregnant Medicaid recipients identify as BIPOC; therefore, providing anti-racist and unbiased care can address and improve maternal health disparities among minority populations.

Opposing Arguments/Evidence
Cost: There are concerns that expanding postpartum care coverage to one year postpartum will be an excess cost burden for state Medicaid budgets. Analyses suggest that birthing people who are uninsured face higher risks of rehospitalization and complications that can lead to greater costs, while health coverage may reduce these high-cost experiences. In addition, there are cost savings associated with improving the health of pregnant-capable people while they are not pregnant through improved management of chronic conditions. 

Postpartum coverage versus full coverage for adults across the life span: Some opposed to extending postpartum coverage instead favor expansion of Medicaid for adults 21 to 64 years of age with incomes up to or above 138% of the federal poverty level as an option under the ACA. Expanding coverage for additional low-income and uninsured adults is necessary to ensure equitable access to care and services among those who have been historically underserved and marginalized. It is not clear that having the postpartum coverage option available reduces the likelihood that states will adopt ACA Medicaid coverage for all low-income adults.

Alternative Strategies
Current federal law permits states to extend Medicaid postpartum coverage through an SPA or a waiver process. Before the passage of the American Rescue Plan Act, some states were pursuing use of the waiver as the only course of action, and the waiver proposal for Illinois has been approved. However, the option to include use of SPAs has several advantages for state governments and birthing people,[22,26,40,42] including the following[50]:

1. Population covered: Waivers often focus on only a share of the population (e.g., women who use substances, women younger than 21 years), whereas the SPA option would provide coverage for the full birthing population in Medicaid.
2. Duration of extended coverage: The SPA extends coverage to one year, while state waiver proposals may be for shorter periods of time. While states may seek approval for less than 12 months in an SPA, the ARPA option explicitly states a full year.
3. Range of benefits: Waiver applications have been used to provide more narrow coverage (e.g., focusing solely on substance use disorder treatment), whereas states that elect to use the SPA can provide full Medicaid benefits during pregnancy and the extended postpartum period. 
4. Consumer protections: Waiver approaches permit states to waive certain federal minimum standards (e.g., choice of family planning provider, no cost sharing), but the SPA would ensure these and other protections.
5. Budget neutrality: Under a waiver, states must demonstrate that federal costs would not be increased; however, an SPA would provide federal matching funds for additional spending without this requirement.
6. Administrative simplicity: The SPA creates parallel one-year continuous coverage for birthing people and their infants following a Medicaid-financed birth. This ensures more opportunities to protect continuous eligibility and provide two-generation care.
7. Consistency across CHIP and Medicaid: Six states (i.e., Colorado, Missouri, New Jersey, Rhode Island, Virginia, and West Virginia) currently provide coverage to pregnant people under CHIP. For states that choose the SPA, one-year postpartum coverage will apply to CHIP-enrolled pregnant people.

Action Steps
In support of this policy, APHA calls for the following actions:

• The U.S. Congress should enact legislation to make national Medicaid postpartum coverage mandatory for one year.
• All states should adopt the option for extending postpartum coverage to one year.
• All states should use SPAs rather than the more limited waiver approaches.
• Health care leaders and planners should maximize Medicaid expanded coverage for the postpartum period by using levers to incentivize quality, adopting evidence-based care approaches, providing team-based care, and encouraging changes in provider practices.
• Health care leaders and planners should ensure Medicaid postpartum coverage of the full Medicaid benefit and the full set of ACA Women’s Preventive Services[45] without cost sharing for all Medicaid beneficiaries.
• Health care leaders and planners should encourage use of Medicaid financing to provide adequate reimbursement for services and for the full range of providers in the perinatal workforce, including but not limited to doulas, midwives, freestanding birth centers, community health workers, physicians, nurses, dentists, and advanced practice nurses.

References
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