Medicaid Extension- Not Expansion- is the Key to Decreasing Maternal Mortality in the United States

Hebron Kelecha, Class of 2021

The United States is the only industrialized nation with a rising maternal mortality rate. These rates are not equally distributed, with Black and American Indian/Alaska Native women being 2-3 times more likely to die of pregnancy-related complications than White women. These alarming rates are not limited to those with lower socioeconomic status but transcend both class and educational level. A study in New York City showed Black women with a college education are more likely to experience life-threatening complications during delivery than a White woman who did not complete high school. 

Despite the United States spending more money on health care than any other country, why are our mothers, especially our Black mothers, dying at alarming rates? These disparities occur for several reasons, one being implicit bias. These pervasive biases we hold about others, which are often unconscious, affect our everyday decisions as providers and can be detrimental for our patients. We are just now beginning to address implicit bias with evidence-based interventions both at the state level through Maternal Mortality and Morbidity Review (MMMR) Committees and nationally through landmark maternal health legislation such as the Preventing Maternal Deaths Act of 2018.

However, acknowledging unconscious bias alone will not solve our high maternal mortality rates. States also need to extend Medicaid coverage. Generally, Medicaid covers low-income women through their pregnancy, birth and postpartum period. Despite pregnancy-related deaths being defined as deaths during pregnancy and up to 365 days after delivery, Medicaid postpartum coverage only extends up to 60 days post-delivery. With 33 percent of pregnancy-related deaths occurring between one week to one year postpartum, our current 60-day postpartum Medicaid coverage is not enough. 

This problem has not been solved by Medicaid expansion alone in states that chose to expand Medicaid. A study of women’s insurance coverage during their pregnancy and postpartum period showed that women in both expansion and non-expansion states experienced a gap in coverage following delivery. In some states, most pregnant mothers rely on Medicaid to cover the costs of their pregnancies. For example, Medicaid finances 65 percent of births in Louisiana. Because Medicaid only covers 60 days post-delivery, most new mothers in Louisiana are not receiving the critical postpartum care that they need. 

Medicaid extension has been supported by several states through their MMMR committees, the American College of Obstetricians and Gynecologists (ACOG) and the American Medical Association (AMA). Additionally, states such as California have begun using state funds to extend the 60-day period of postpartum eligibility to 365 days for women diagnosed with mental health conditions. Some states are seeking 1115 waivers from the Centers for Medicare and Medicaid Services (CMS), and federal efforts are underway both within the House and Senate. 

The postpartum period is a vulnerable time for mothers in which comprehensive, continuous coverage is essential to their wellbeing. Without affordable access to medical care throughout their postpartum period, maternal mortality rates will continue to rise. If we can’t decide on Medicaid expansion, I urge us to lean in on conversations surrounding improving the systems already in place.

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