off the charts
POLICY INSIGHT
BEYOND THE NUMBERS

Congress Should Advance Maternal Health Equity in Upcoming Economic Legislation

Federal lawmakers have a critical opportunity to address the Black maternal health crisis and rising maternal mortality rate by closing the Medicaid coverage gap and requiring states to provide 12 months of postpartum coverage in their Medicaid programs. These actions would help ensure more people can get the health care they need before, during, and after pregnancy, which will be key to reducing the U.S.’ high maternal mortality rate.

The country’s maternal health crisis is only getting worse — the latest data from the Centers on Disease Control and Prevention show that the maternal mortality rate rose in 2020. And in that year, Black people who gave birth experienced very high and rising mortality rates compared to white people.

Structural racism is a key factor behind the stark differences in Black and white maternal mortality rates. Many policies and practices particularly limit access to comprehensive and affordable care for Black people; for example, occupational segregation driven by employer bias and inequity in education, among other factors, results in Black people being less likely to have jobs with affordable employer-based coverage. Furthermore, discrimination and bias within the health care system lead to poorer treatment, and racism has its own direct impacts on individual health, such as higher levels of chronic stress. Black mothers are three times as likely as white mothers to die from pregnancy-related causes. They’re also more likely to have a severe health complication, or a “near miss,” with potentially long-term effects on their health.

Medicaid is well-positioned to help reduce high rates of death and severe health complications among people who give birth. Medicaid paid for 42 percent of all births nationally in 2020, including 65 percent of births by Black mothers and 59 percent of births by Latina mothers. Policymakers can maximize the program’s benefits by requiring states to extend Medicaid’s postpartum coverage from its current 60 days to 12 months, as well as by eliminating the coverage gap, in which adults with low incomes —including over 800,000 women of reproductive age — have no pathway to affordable coverage because their state is one of 12 that has refused to expand Medicaid.

Of the 2.2 million adults in the coverage gap in 2019, more than one-third were women of reproductive age and 60 percent were people of color. If they become pregnant, they qualify for Medicaid because all states cover pregnant people with incomes below 138 percent of the poverty line (and many at higher income levels). But necessary preconception care is likely unavailable and being uninsured before pregnancy is associated with a higher prevalence of risk factors that contribute to poor pregnancy outcomes, especially for Black women. Health coverage can help ensure that people start a pregnancy in good overall health and that they get care for postpartum complications that can arise many months after they give birth.

Without access to care prior to pregnancy, people with chronic conditions may be at increased risk of pregnancy complications or death due to an inability to manage or treat conditions like diabetes or hypertension. In states that expanded their Medicaid programs under the Affordable Care Act (ACA), more women have been able to get health coverage before becoming pregnant. Research shows Medicaid expansion is associated with reduced rates of maternal death, particularly for Black women.

Medicaid also plays an important role in keeping women healthy in the critical postpartum period. Postpartum health coverage allows people to get treatment for chronic health conditions, like hypertension and heart disease, and mental health conditions, like postpartum depression, which are major contributors to poor health outcomes for mothers after delivery.

Postpartum coverage can also help prevent pregnancy-related deaths. Two in three pregnancy-related deaths were determined to be preventable and about 24 percent of pregnancy-related deaths occurred between 43 and 365 days postpartum, according to a review of data from 14 maternal mortality review committees. Postpartum coverage is especially important for Black people, who are somewhat likelier to experience life-threatening pregnancy complications in the late postpartum period (between six weeks and one year after childbirth) than white people.

States can submit waivers or take advantage of the American Rescue Plan’s new state plan amendment option — which started on April 1, 2022 and will be available for five years — to extend postpartum coverage from 60 days to 12 months. As of May 19, 29 states and D.C. have done so or announced that they would, and that includes nine states that haven’t expanded Medicaid.

That over half of states so far are extending postpartum coverage is a tremendous step forward in addressing high rates of death and severe health complications for Black people who give birth. But access to postpartum care shouldn’t depend on where someone lives. Federal action to require states to make a full year of postpartum coverage available in all states is the appropriate response to the troubling trend of worsening health among people who give birth in this country.

As explained above, in the 12 states that refused to expand Medicaid, many low-income people have to wait until they become pregnant to get health insurance. Most of the non-expansion states are in the South, a region where over half of the country’s Black population lives and which ranks low on many maternal health outcome measures. Addressing health care access challenges in the South is a critical piece of addressing the high rates of death and severe health complications among Black people who give birth.

Closing the coverage gap and ensuring 12 months of postpartum coverage in every state would be a step toward greater health justice in those states where many Black people have been denied comprehensive preconception, prenatal, and postpartum care.