Despite Many States Doing What They Can, The Federal Government Must Act Now To Extend Postpartum Medicaid Coverage

According to data from the Centers for Disease Control and Prevention, more than 40,000 pregnant women have been infected with COVID-19, and upwards of 8,000 have been admitted to the hospital for treatment since January 22, 2020. More than 50 pregnant women have died. Although, because only about a third of COVID-19 case report forms include information on pregnancy status, these numbers are likely an underestimate of the number of pregnant women in the United States with COVID-19.

In the United States, Medicaid is the largest payer of maternity care. Millions of women rely on Medicaid during their pregnancy to obtain necessary and essential health care; yet, under federal law, many women lose coverage 60 days after the end of pregnancy. During the COVID-19 pandemic, at the urging of many, including the American College of Obstetricians and Gynecologists, Congress enacted a temporary fix preventing states from terminating Medicaid coverage for pregnant and postpartum women during the COVID-19 public health emergency. Unfortunately, if further action is not taken before the public health emergency ends, individuals, especially those with low incomes and those impacted by job loss, will once again be at risk of losing coverage in the postpartum period. This loss of coverage could threaten their lives; indeed, a growing number of maternal deaths occur during the postpartum period when many women relying on Medicaid are at risk of losing coverage.

It is essential that both federal and state governments implement policy solutions that preserve care for women in the postpartum period. Extension of Medicaid coverage for the full year after delivery is a critical step in our nation’s efforts to combat unacceptable maternal mortality and morbidity rates.

State Efforts To Extend Postpartum Coverage: An Update

The COVID-19 pandemic has had a varied impact on state efforts to extend postpartum coverage for women with a Medicaid-covered birth (exhibit 1). Several states—including Tennessee, Virginia, and Washington—had to halt efforts to extend coverage because of budgetary concerns (although Tennessee and Virginia’s efforts have come back around again). Others—including California, Michigan, and Texas—were able to fend off threats and stay the course. And most recently, Georgia Governor Brian Kemp signed a fiscal year 2021 budget that includes $19 million in new funding to extend postpartum coverage to six months, and Indiana submitted a Section 1115 waiver to the Centers for Medicare and Medicaid Services (CMS) seeking approval to implement a coverage extension for women with substance use disorder.

Two states—California and Texas—have managed to implement versions of a postpartum coverage extension during the pandemic using state-only dollars. Prior to the pandemic, California passed legislation to provide 12 months of postpartum coverage for women with a maternal mental health condition. After facing both a budgetary and statutory cut to the program, California became the first state in the nation to implement its program, which formally launched on August 1. On September 1, following on the heels of California’s success, Texas launched its version of a limited postpartum coverage extension. Under a new program titled Healthy Texas Women Plus, the state is providing an enhanced postpartum care services package for eligible women enrolled in Healthy Texas Women, the state’s family planning program.

While there are well-placed concerns with the underlying Healthy Texas Women program, beneficiaries of this new program will be eligible to receive “physical health, mental health, and substance use disorder services that address asthma, diabetes, hypertension, certain cardiovascular conditions, perinatal mood and anxiety disorders including postpartum depression, and substance use disorders including drug, alcohol, and tobacco use.” While currently funded with state-only dollars, Texas plans to pursue Section 1115 waiver authority to draw down federal funds for these enhanced postpartum services.

Exhibit 1: State efforts to extend Medicaid coverage for pregnant women beyond 60 days postpartum  

Source: Author’s analysis as of November 20, 2020. Note: California, South Carolina, and Texas are currently operating limited extensions of postpartum coverage.

The success of California and Texas’s efforts, despite seemingly insurmountable odds given the fiscal crises faced by states, signals that extending postpartum coverage continues to be a top priority. Prior to the pandemic, three states—Illinois, Missouri, and New Jersey—had submitted Section 1115 waivers to CMS seeking authority to extend postpartum coverage. Illinois—whose waiver was certified in January 2020—wants to extend postpartum coverage to 12 months after the end of pregnancy for all women enrolled in the state’s Medicaid program. Missouri and New Jersey—whose waivers were certified in February and March, respectively—are both seeking more limited extensions of coverage. Missouri is seeking to extend coverage to 12 months for postpartum women enrolled in substance use disorder treatment prior to 60 days after the end of pregnancy. New Jersey is seeking to extend coverage to six months postpartum for women earning between 138 percent and 199 percent of federal poverty level.

Understandably, at the outset of the pandemic, routine CMS activity around consideration of Section 1115 waivers was put on pause as state and federal Medicaid efforts focused on pandemic-related flexibilities. Recently, however, it has become clear that CMS staff have resumed their regular activity. In the span of five days in October, CMS approved harmful work requirement waivers from Georgia and Nebraska. As of this writing, while rates of COVID-19 infection continue to rise in all areas of the country and the nation’s maternal mortality crisis persists, the postpartum extension wavier requests from Illinois, Missouri, New Jersey, and now Indiana, continue to go unanswered. 

The Final Moments Of The 116th Congress And What’s To Come For Postpartum Coverage

As states across the political spectrum continue to pursue this lifesaving policy, while grappling with budget crises and competing legislative and regulatory priorities in the wake of this pandemic, Congress must  make extending postpartum coverage easier to achieve. On September 29, the US House of Representatives unanimously passed H.R. 4996, the bipartisan Helping Medicaid Offer Maternity Services (Helping MOMS) Act, to create a state option under the Medicaid program to extend postpartum coverage. As we move into the lame duck session and the close of the 116th Congress, the pressure is on for the US Senate to act now.

As a member of the Black Maternal Health Caucus, Vice President-elect Kamala Harris has been a steadfast advocate for improving women’s access to health care and eliminating racial inequities in maternal health outcomes. While there is reason to predict that the Biden-Harris administration will support policies that protect and advance maternal health, these policies will take some time to achieve while the nation’s maternal mortality crisis persists. It is imperative that, before the end of the year, Congress makes the option of extending postpartum coverage a reality for the states. Once this critical step is achieved, advocates can work to build on this success with more policies aimed at ending preventable maternal mortality and addressing unacceptable inequities in maternal health outcomes.

Moms can’t wait. Providing 12 months of continuous coverage for women after the end of pregnancy is more critical now than ever.