Medicaid, the publicly funded insurance program for low-income and disabled individuals covers 43.1 percent of all births in the U.S. Unfortunately, vital pregnancy-related coverage ends just 60 days after giving birth for most people on Medicaid. Black and Latinx women, as well as other birthing people of color, make up a disproportionate share of Medicaid enrollees. Research has shown that closing gaps in coverage could improve lactation and human milk feeding support, assist with family transitions and the physical and emotional recovery of birthing people.
Lack of insurance and transitions between plans disrupts trusted relationships between patients and providers who work together to address conditions such as diabetes, high blood pressure and other chronic conditions before a person becomes pregnant or during early prenatal care. Extending Medicaid coverage to 12 months would likely prevent many of the roughly 12 percent of pregnancy-related deaths occurring after six weeks postpartum.
Despite the coverage gains made under the Affordable Care Act, women of color are still more likely to be uninsured, even during the perinatal period. Coverage gaps also create harmful barriers to seeking care and receiving help for complications after giving birth, including access to mental health services for the one in 10 birthing people who will experience postpartum depression, not to mention the stress of taking on the out-of-pocket costs associated with not having insurance or being underinsured. Additionally, the Affordable Care Act provides necessary coverage for community-based lactation support and human milk feeding resources—breastfeeding, chest-feeding and the provision of expressed human milk. Human milk feedings have been shown to improve health outcomes across the life course for birthing people and their infants, increase bonding between the dyad, and reduce health care costs.
Medicaid expansion is an ethical imperative and moral duty of federal and state governments to protect the health and welfare of the most vulnerable populations in our society. Comprehensive insurance coverage must become the standard ethic of care and a moral priority in efforts to reduce the impact of maternal mortality and morbidity and improve health and wellness during the postpartum period. With no federal mandate, the 12 states that have continued to deny access to insurance through Medicaid expansion will likely forgo extending postpartum Medicaid. It is shameful that this is our reality during the COVID-19 global pandemic.
One additional consideration is the missed opportunities of the pandemic—namely, shelter-in-place regulations that could have served as a pilot program to extend postpartum Medicaid and pay workers to stay home. By focusing on workers who are hardest hit by COVID-19, we could have accomplished complementary goals given these workers are the same people who are likely eligible for expanded postpartum Medicaid coverage. A recent report from TimesUp makes the case for a worker-centered recovery. Findings showed that 52 percent of Latina women and 44 percent of Black women anticipated losing paid work as a result of unpaid caregiving responsibilities, compared to 30 percent of men.
In addition, one in four birthing people have to return to work within 10–14 days after giving birth. The lack of paid family leave, coupled with the potential loss of health care coverage, further perpetuates health inequities and disparities. One state, California, expanded Medi-Cal (the state version of Medicaid) by the Provisional Postpartum Care Extension (PPCE) in 2019. The PPCE includes extended Medi-Cal coverage, across the first year of the postpartum period, for birthing individuals diagnosed with a perinatal mental health condition during pregnancy or up to 90 days after birth. We believe these policies should be the standard of coverage for all pregnant-capable people, regardless of insurance payor and mental health diagnoses.
Extending postpartum Medicaid coverage to 12 months saves lives and promotes health, and the U.S. is one step closer to making this a reality. Representatives Alma Adams (D–N.C.) and Lauren Underwood (D–Ill.) reintroduced the Momnibus bill, which is a sweeping legislation that consists of 12 separate bills to address maternal morbidity, mortality, mental health, workforce and payment models to stem the U.S. maternal health crisis. The Momnibus would help to build on the ongoing effort to secure the Medicaid coverage extension, which has long been considered low-hanging fruit.
Within days of the reintroduction, the House of Representatives announced on February 11, 2021, that the Energy and Commerce Committee would fast-track review of postpartum coverage, which provides an option for states to extend Medicaid coverage to 12 months after birth. The provision was passed by Congress and signed into law on March 11 by President Joe Biden as part of the American Rescue Plan Act. Unfortunately, this optional expansion would not be universally applied, would expire in five years if not renewed and would not have matched federal funds—shameful when considering an estimated 60 percent of maternal deaths occur in the postpartum period and that a majority of maternal deaths are considered preventable.
We applaud the organizations that have worked to support both the Momnibus and extension of Medicaid during the postpartum period. Despite the obvious shortcomings of these policies, including the exclusion of undocumented birthing people, it is important to remember, this is a floor and not the ceiling. Expanded health care coverage must go hand-in-hand with access to quality care, redress of systemic barriers to vital health, and social services and supports, as well as targeted interventions for eliminating racism and sexism within the health care system.
This is an opinion and analysis article.