Thursday, April 22, 2021

Expanding Post-Partum Medicaid Is a Step in the Right Direction but More Remains To Be Done

By Genevieve Marcy (April 22, 2021)

The Biden administration has touted the American Rescue Plan as “one of the most progressive pieces of legislation in history.” Included in the legislation is a provision that promotes reproductive justice and the health and human rights of pregnant and birthing people by allowing states to expand Medicaid to cover birthing parents up to one-year post-partum. While the new provision represents an important step forward, by extending the time period Medicaid covers pregnant people after birth, the expansion will not provide coverage for pre-pregnancy health issues that cause and exacerbate pregnancy-related health concerns. Pregnancy-related health conditions do not arise in a vacuum, and they do not disappear one year after birth. Additionally, by allowing states to decide whether to opt-in to the expanded coverage, this expansion may do little to shrink the disparities in health outcomes and maternal mortality rates between the states.

To be clear, any increase in Medicaid coverage for birthing parents will have a positive effect on maternal health. The United States has the highest maternal mortality rate among wealthy nations, likely due in part to our country’s high rates of uninsurance. Currently, the Medicaid provision that covers birthing parents extends only 6 weeks after birth—even though a full third of pregnancy-related deaths occur between 1 week and 1 year after birth. Expanding Medicaid coverage also could help fight racial disparities in maternal mortality, as Black women and Native women are much more likely to suffer pregnancy-related deaths, and have higher rates of cardiovascular issues that can be especially dangerous post-partum.

While racial disparities in maternal mortality rates cannot be explained by deficient healthcare alone, inadequate care before pregnancy contributes to the elevated maternal mortality rate faced by Black pregnant people and other pregnant people of color. Conditions that could have been treated or prevented with regular access to healthcare—like cardiovascular disorders or diabetes—can become dangerous or even deadly during pregnancy. Even if Medicaid coverage allows an individual to access appropriate care during pregnancy, nine months is often not long enough to solve health problems that have been brewing for years. Similarly, while extending Medicaid coverage for one year post-partum will help prevent many pregnancy-related deaths, pregnancy-related health complications can continue to affect a person’s health for years after giving birth.

There remain significant challenges for people to obtain and keep Medicaid coverage before and after pregnancy that stem from states’ ability to opt out of expanding eligibility. Twelve states refused to expand Medicaid eligibility under the Affordable Care Act. These states are primarily in the southeast and have higher Black populations than average—meaning that the decision to refuse Medicaid expansion in these states has had a disproportionate effect on Black Americans. Leaving the decision to expand post-partum Medicaid coverage to the states is likely to replicate and exacerbate this disparity.  This has led Rep. Ayanna Pressley to introduce a bill that would make the ARP extension of Medicaid coverage for one year post partum mandatory for states.

In its most recent concluding observations on the US, the U.N. Committee on the Elimination of Racial Discrimination, which oversees compliance with the Convention on the Elimination of All Forms of Racial Discrimination, pointed out that allowing states to opt-out of Medicaid expansion prevented the ACA from adequately addressing racial disparities in access to health care. The Committee specifically recognized the link between racial disparities in maternal and infant mortality and Medicaid coverage and called on the federal government to take action to reduce the disparity. While the post-partum Medicaid expansion is a solid step in the right direction, allowing states to opt-out means that, like the ACA, the ARP provision’s effect on racial disparities in maternal mortality will be limited. The US should build on the ARP by making the one year post-partum expansion mandatory and taking steps to ensure that all people in every state have access to the care they need—whether they are post-partum or not.

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