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When tennis star Serena Williams shared her potentially fatal postpartum experience in 2018, she helped spotlight the racial bias Black pregnant women and new mothers face and the disproportionate rate of maternal deaths and “near misses” they experience. She desperately pleaded for the nurse to provide what Williams knew to be the care she needed, given her history of blood clots. Ultimately, it was Williams’s persistence that saved her life. Had it not been for Serena Williams’s heroic self-advocacy and understanding of what medical treatment she needed, her situation very likely could have been life threatening.
This week (April 11-17) marks Black Maternal Health Week, an annual event dedicated to highlighting the alarming statistics around Black maternal health and calling for policies that center birth and reproductive justice. Compared to white women, Black women are 3–4 times more likely to die from pregnancy-related causes, and more than twice as likely to experience severe maternal morbidity (“near misses”). Black LGBTQI+ individuals, particularly Trans people, face additional barriers to care through stigma and discrimination.
This year, state health advocates have an important opportunity to take concrete action addressing maternal health inequities, thanks to the American Rescue Plan Act (ARPA). Every state has the ability to extend Medicaid coverage from 60 days to 12 months postpartum, thereby providing health coverage to low-income mothers during a time period when up to one-third of maternal deaths occur. Moreover, those states that have not yet expanded Medicaid eligibility to more low-income people, as provided under the Affordable Care Act, have new incentives to expand Medicaid, which would give year-round health coverage to more women and other birthing people before, during and after pregnancy.
In recognition of Black Maternal Health Week, the Biden-Harris administration announced executive actions on Tuesday to address racial disparities in maternal health, one of which was the approval of the first Medicaid Section 1115 waiver from Illinois to extend Medicaid postpartum coverage to 12 months postpartum. Other states will be able to follow Illinois’ example using a simpler state plan amendment process allowed under the ARPA. "The postpartum period is an important part of maternity care, and it is a time when mothers may be dealing with a host of medical conditions," HHS Secretary Xavier Becerra said.
Why are Black women and birthing people experiencing maternal health inequities?
The short answer is systemic racism. One of the manifestations of this structural racism is limited access to health insurance, specifically Medicaid coverage for low-income Black women and birthing people.
Despite the coverage gains from the ACA, which allows states to expand Medicaid to cover more people, 14 percent of Black women remain uninsured. These uninsured rates can be predominantly attributed to the decisions by states not to expand their Medicaid programs to include low-income adults. In fact, state decisions not to expand Medicaid disproportionately affect Black Americans in their access to insurance. Uninsured Black adults are nearly twice as likely as white uninsured adults to fall into the coverage gap in states that have not yet expanded.
Medicaid coverage is an essential element of any plan to address maternal health inequities affecting low-income Black pregnant women and birthing people. When states expand their Medicaid program to bridge the coverage gap, there is an increase in preconception and postpartum Medicaid coverage — coverage that is associated with a 28 percent reduction in insurance churn during the perinatal period. Beyond limiting insurance churn, Medicaid expansion has improved access to care, increased the use of health services and led to better self-reported health among women of reproductive age, which could lead to healthier starts to pregnancies.
In expansion and non-expansion states alike, pregnant people can also qualify for Medicaid coverage through the pregnancy eligibility category. The higher income threshold associated with the pregnancy eligibility category allows for more people to enroll in health care coverage to meet their prenatal, childbirth and postpartum needs. The coverage period associated with this eligibility category has historically been restricted to the pregnancy period and 60 days postpartum. This limited coverage period leaves more than one-third of people uninsured before or after pregnancy. The churn in coverage and higher rates of un-insurance among Black pregnant women and birthing people compared to white pregnant women and birthing people correlate with disproportionately higher rates of maternal mortality among Black mothers.
What does the ARPA to help address alarming maternal mortality rates?
1. Option for states to extend their postpartum coverage period from 60 days to 12 months postpartum. ARPA gives states the option to extend Medicaid postpartum coverage from 60 days to a full year and facilitates the process by which states can opt to extend the postpartum period. Under the ARPA provision, states can obtain the postpartum extension by filing a State Plan Amendment (SPA), an easier and faster process compared to 1115 waivers (though six states have applied for a postpartum extension through an 1115 waiver, only Illinois has received an approval). A SPA not only expedites the extension process, it will also ensure that states get the same federal funding match rate across the extension period. If a state chooses to opt to extend their Medicaid postpartum periods, the SPA could go into effect as early as April 1, 2022.
We are expecting additional guidance from CMS that provides more concrete steps for how states might pursue, and how our state partners may advocate for, the postpartum extension.
2. Incentives for states to expand Medicaid. ARPA provides a temporary increase to the state’s base Federal Medical Assistance Percentage (FMAP) by five percentage points for two years for states that newly expand Medicaid. Notably, this applies to all eligibility groups, with the exception of the expansion group, that would receive a 90 percent enhanced FMAP. This expansion provision is a robust step toward addressing the coverage gap for low-income individuals in non-expansion states. The provision creates a financial incentive that exceeds what states would have gained from simply restoring 100% FMAP for expansion populations as originally designed in the ACA.
Medicaid expansion could reduce both preconception and postpartum uninsured rates for women and birthing people and allow greater access to health care needed to address underlying conditions that can cause higher rates of mortality and morbidity.
The passage of ARPA, which contains these important and life-saving provisions, aligns well with Black Maternal Health Week, as we now have concrete policy options to address maternal health disparities for Black women and birthing people. We want to see every state act to extend the Medicaid postpartum period and the federal government must act quickly to approve those extensions to ensure that low-income postpartum women and birthing people have coverage when they need it most.